go back

Maine rates for HCPCS 15120

Split-thickness autograft, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits; first 100 sq cm or less, or 1% of body area of infants and children (except 15050)

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$2,754.23 / $2,754.23 / $5,248.07
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$549.54 / $794.33 / $2,041.74
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$707.95 / $1,000.00 / $1,380.38
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$758.58 / $1,047.13 / $1,905.46
Harvard Pilgrim
Facility/Professional
Professional
Modifier
Low / Median / High Price
$758.58 / $1,071.52 / $1,698.24
Martin's Point
Facility/Professional
Facility
Modifier
Low / Median / High Price
$2,754.23 / $2,754.23 / $5,248.07
Martin's Point
Facility/Professional
Professional
Modifier
Low / Median / High Price
$645.65 / $954.99 / $2,454.71
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$758.58 / $1,071.52 / $1,698.24