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Montana rates for HCPCS 15200

Full thickness graft, free, including direct closure of donor site, trunk; 20 sq cm or less

Insurance Carrier
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$604.79 / $750.33 / $3,530.87
BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,064.75 / $1,064.75 / $1,331.33
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,064.75 / $1,064.75 / $1,064.75
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$828.22 / $1,120.34 / $1,370.61
Providence
Facility/Professional
Facility
Modifier
Low / Median / High Price
$595.66 / $818.21 / $1,495.40
Providence
Facility/Professional
Professional
Modifier
Low / Median / High Price
$791.51 / $1,131.93 / $1,579.55
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,210.46 / $1,387.93 / $1,516.67