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Maine rates for HCPCS 15221

Full thickness graft, free, including direct closure of donor site, scalp, arms, and/or legs; 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
$1,120.50 / $1,120.50 / $1,120.50
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$56.08 / $108.35 / $125.87
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$76.20 / $123.24 / $193.55
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$76.18 / $139.13 / $268.83
Harvard Pilgrim
Facility/Professional
Professional
Modifier
Low / Median / High Price
$84.91 / $150.71 / $264.41
Martin's Point
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,120.50 / $1,120.50 / $1,120.50
Martin's Point
Facility/Professional
Professional
Modifier
Low / Median / High Price
$56.07 / $108.35 / $206.48
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$109.59 / $186.98 / $259.89