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Virginia 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
$150.78 / $4,771.00 / $8,294.00
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$220.67 / $220.67 / $220.67
Kaiser Permanente
Facility/Professional
Professional
Modifier
Low / Median / High Price
$213.18 / $239.47 / $285.08
Medcost
Facility/Professional
Facility
Modifier
Low / Median / High Price
$129.02 / $210.38 / $361.04
Sentara
Facility/Professional
Facility
Modifier
Low / Median / High Price
$137.55 / $201.21 / $1,098.00
United
Facility/Professional
Facility
Modifier
Low / Median / High Price
$296.00 / $1,045.00 / $2,364.00