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Pennsylvania 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
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$69.02 / $2,463.00 / $7,799.00
Capital Blue Cross
Facility/Professional
Facility
Modifier
Low / Median / High Price
$3,736.00 / $4,444.00 / $15,949.31
Martin's Point
Facility/Professional
Facility
Modifier
Low / Median / High Price
$594.00 / $2,679.00 / $8,017.00
Priority Health
Facility/Professional
Facility
Modifier
Low / Median / High Price
$129.19 / $129.19 / $129.19
UPMC Health Plan
Facility/Professional
Facility
Modifier
Low / Median / High Price
$74.54 / $98.20 / $151.60
United
Facility/Professional
Facility
Modifier
Low / Median / High Price
$144.00 / $650.00 / $4,300.00