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Wisconsin 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
$61.66 / $151.36 / $3,090.30
Anthem BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$2,041.74 / $2,630.27 / $6,165.95
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$371.54 / $426.58 / $691.83
DeanCare
Facility/Professional
Facility
Modifier
Low / Median / High Price
$72.44 / $213.80 / $3,715.35
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$74.13 / $204.17 / $1,659.59
Quartz
Facility/Professional
Professional
Modifier
Low / Median / High Price
$125.89 / $234.42 / $489.78
Quartz
Facility/Professional
Facility
Modifier
Low / Median / High Price
$190.55 / $1,995.26 / $1,995.26
United
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,023.29 / $1,584.89 / $1,949.84