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Montana rates for HCPCS 15130

Dermal autograft, trunk, arms, legs; first 100 sq cm or less, or 1% of body area of infants and children

Insurance Carrier
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$537.03 / $741.31 / $1,819.70
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$954.99 / $954.99 / $954.99
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$602.56 / $954.99 / $1,148.15
MountainHealth Co-op
Facility/Professional
Facility
Modifier
Low / Median / High Price
$977.24 / $1,148.15 / $1,348.96
MountainHealth Co-op
Facility/Professional
Professional
Modifier
Low / Median / High Price
$977.24 / $1,148.15 / $1,348.96
Providence
Facility/Professional
Facility
Modifier
Low / Median / High Price
$549.54 / $776.25 / $1,230.27
Providence
Facility/Professional
Professional
Modifier
Low / Median / High Price
$79.43 / $933.25 / $1,380.38
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$891.25 / $1,047.13 / $1,318.26