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New Hampshire 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
$2,398.83 / $3,019.95 / $9,772.37
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$549.54 / $741.31 / $1,995.26
Anthem BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$3,467.37 / $4,677.35 / $6,309.57
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$616.60 / $1,071.52 / $1,621.81
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,819.70 / $1,819.70 / $1,819.70
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$707.95 / $1,122.02 / $2,089.30
Harvard Pilgrim
Facility/Professional
Facility
Modifier
Low / Median / High Price
$10,000.00 / $10,000.00 / $10,000.00
Harvard Pilgrim
Facility/Professional
Professional
Modifier
Low / Median / High Price
$741.31 / $1,288.25 / $2,290.87
United
Facility/Professional
Facility
Modifier
Low / Median / High Price
$10,000.00 / $10,000.00 / $10,000.00
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$794.33 / $1,230.27 / $2,398.83
Well Sense
Facility/Professional
Facility
Modifier
Low / Median / High Price
$870.96 / $870.96 / $1,071.52