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Pennsylvania 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
$724.44 / $3,801.89 / $8,317.64
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$58.88 / $114.82 / $363.08
Capital Blue Cross
Facility/Professional
Facility
Modifier
Low / Median / High Price
$2,344.23 / $2,570.40 / $57,543.99
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$66.07 / $114.82 / $194.98
Emblem Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$162.18 / $208.93 / $229.09
Geisinger
Facility/Professional
Professional
Modifier
Low / Median / High Price
$87.10 / $165.96 / $263.03
Martin's Point
Facility/Professional
Facility
Modifier
Low / Median / High Price
$831.76 / $2,691.53 / $8,317.64
Martin's Point
Facility/Professional
Professional
Modifier
Low / Median / High Price
$60.26 / $120.23 / $371.54
Oscar Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$109.65 / $109.65 / $109.65
UPMC Health Plan
Facility/Professional
Facility
Modifier
Low / Median / High Price
$67.61 / $138.04 / $407.38
UPMC Health Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$67.61 / $128.82 / $407.38
United
Facility/Professional
Facility
Modifier
Low / Median / High Price
$144.54 / $645.65 / $4,265.80
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$63.10 / $112.20 / $204.17