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New Hampshire 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
Facility
Modifier
Low / Median / High Price
$76.01 / $1,749.77 / $8,965.00
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$33.31 / $53.69 / $78.20
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$42.37 / $76.98 / $143.13
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$46.72 / $98.44 / $206.18
Harvard Pilgrim
Facility/Professional
Professional
Modifier
Low / Median / High Price
$53.66 / $119.61 / $242.78
United
Facility/Professional
Facility
Modifier
Low / Median / High Price
$7,448.00 / $7,448.00 / $7,448.00
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$105.14 / $129.33 / $278.88
Well Sense
Facility/Professional
Professional
Modifier
Low / Median / High Price
$39.13 / $62.82 / $87.95