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Montana rates for HCPCS 15240

Full thickness graft, free, including direct closure of donor site, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands, and/or feet; 20 sq cm or less

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$5,370.32 / $5,370.32 / $5,370.32
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$741.31 / $933.25 / $1,862.09
BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$46,773.51 / $81,283.05 / $95,499.26
BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,071.52 / $1,258.93 / $1,479.11
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,258.93 / $1,258.93 / $1,258.93
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$776.25 / $1,258.93 / $1,548.82
MountainHealth Co-op
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,348.96 / $1,584.89 / $1,737.80
MountainHealth Co-op
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,348.96 / $1,584.89 / $1,737.80
Providence
Facility/Professional
Facility
Modifier
Low / Median / High Price
$691.83 / $933.25 / $1,548.82
Providence
Facility/Professional
Professional
Modifier
Low / Median / High Price
$79.43 / $1,258.93 / $1,778.28
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,202.26 / $1,445.44 / $1,698.24