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Montana rates for HCPCS 15274

Application of skin substitute graft to trunk, arms, legs, total wound surface area greater than or equal to 100 sq cm; each additional 100 sq cm wound surface area, or part thereof, or each additional 1% of body area of infants and children, or part thereof (List separately in addition to code for primary procedure)

Insurance Carrier
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$38.27 / $62.71 / $128.06
BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$64,999.99 / $77,999.99 / $94,999.99
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$69.41 / $69.41 / $69.41
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$59.00 / $77.95 / $127.77
Providence
Facility/Professional
Facility
Modifier
Low / Median / High Price
$39.95 / $75.36 / $122.99
Providence
Facility/Professional
Professional
Modifier
Low / Median / High Price
$59.00 / $86.12 / $158.72
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$113.68 / $133.34 / $145.26