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Utah rates for HCPCS 15155

Tissue cultured skin autograft, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits; first 25 sq cm or less

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$676.08 / $3,388.44 / $4,897.79
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$602.56 / $724.44 / $1,202.26
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$660.69 / $933.25 / $1,202.26
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$32.36 / $33.11 / $1,148.15
Regence BlueShield
Facility/Professional
Facility
Modifier
Low / Median / High Price
$5,888.44 / $6,918.31 / $13,803.84
Regence BlueShield
Facility/Professional
Professional
Modifier
Low / Median / High Price
$812.83 / $1,047.13 / $1,380.38
Select Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$776.25 / $1,023.29 / $1,380.38
U of Utah Health Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$870.96 / $1,071.52 / $1,584.89
United
Facility/Professional
Facility
Modifier
Low / Median / High Price
$2,137.96 / $5,128.61 / $8,317.64
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$588.84 / $758.58 / $1,148.15