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Texas rates for HCPCS 15121

Split-thickness autograft, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits; each additional 100 sq cm, or each additional 1% of body area of infants and children, or part thereof (List separately in addition to code for primary procedure)

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$280.55 / $3,102.00 / $10,836.00
BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,336.08 / $2,476.51 / $6,612.00
Christus
Facility/Professional
Facility
Modifier
Low / Median / High Price
$116.41 / $116.41 / $213.57
Lucent Health
Facility/Professional
Facility
Modifier
Low / Median / High Price
$641.73 / $26,542.00 / $26,542.00
Moda Health
Facility/Professional
Facility
Modifier
Low / Median / High Price
$122.89 / $198.07 / $364.84
Providence
Facility/Professional
Facility
Modifier
Low / Median / High Price
$122.89 / $198.63 / $380.41
United
Facility/Professional
Facility
Modifier
Low / Median / High Price
$161.00 / $950.00 / $2,290.00