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Utah 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
$977.24 / $3,715.35 / $6,025.60
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$630.96 / $831.76 / $2,344.23
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$724.44 / $1,000.00 / $1,318.26
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$32.36 / $33.11 / $3,090.30
Regence BlueShield
Facility/Professional
Facility
Modifier
Low / Median / High Price
$5,888.44 / $6,918.31 / $13,803.84
Regence BlueShield
Facility/Professional
Professional
Modifier
Low / Median / High Price
$758.58 / $1,122.02 / $1,949.84
Select Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$758.58 / $1,000.00 / $1,584.89
U of Utah Health Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$851.14 / $1,071.52 / $2,041.74
United
Facility/Professional
Facility
Modifier
Low / Median / High Price
$2,137.96 / $5,128.61 / $8,317.64
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$616.60 / $812.83 / $1,230.27