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Montana rates for HCPCS 15152

Tissue cultured skin autograft, trunk, arms, legs; 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
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$218.78 / $218.78 / $218.78
MountainHealth Co-op
Facility/Professional
Facility
Modifier
Low / Median / High Price
$234.42 / $257.04 / $281.84
Providence
Facility/Professional
Facility
Modifier
Low / Median / High Price
$120.23 / $158.49 / $275.42