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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
$5,332.86 / $5,332.86 / $5,332.86
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$691.22 / $856.37 / $1,514.91
BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$47,000.00 / $77,999.99 / $94,999.99
BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,069.06 / $1,257.71 / $1,472.77
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,257.71 / $1,257.71 / $1,257.71
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$925.56 / $1,333.94 / $1,540.55
Providence
Facility/Professional
Facility
Modifier
Low / Median / High Price
$708.94 / $933.86 / $1,790.91
Providence
Facility/Professional
Professional
Modifier
Low / Median / High Price
$879.61 / $1,257.71 / $1,749.63
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,299.97 / $1,548.29 / $1,681.47