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Wisconsin 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
$109.09 / $415.46 / $6,461.00
Anthem BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$5,479.00 / $5,692.00 / $7,344.00
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$542.47 / $633.91 / $972.46
DeanCare
Facility/Professional
Facility
Modifier
Low / Median / High Price
$127.44 / $240.05 / $553.95
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$139.12 / $346.50 / $1,590.00
Prevea360
Facility/Professional
Facility
Modifier
Low / Median / High Price
$127.44 / $240.05 / $553.95
Quartz
Facility/Professional
Professional
Modifier
Low / Median / High Price
$293.49 / $441.81 / $665.31
Quartz
Facility/Professional
Facility
Modifier
Low / Median / High Price
$244.61 / $326.92 / $594.91
United
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,034.00 / $1,423.00 / $2,202.90