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Montana rates for HCPCS 15201

Full thickness graft, free, including direct closure of donor site, trunk; each additional 20 sq cm, or part thereof (List separately in addition to code for primary procedure)

Insurance Carrier
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$120.23 / $120.23 / $120.23
MountainHealth Co-op
Facility/Professional
Facility
Modifier
Low / Median / High Price
$128.82 / $162.18 / $251.19
Providence
Facility/Professional
Facility
Modifier
Low / Median / High Price
$66.07 / $120.23 / $213.80