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Pennsylvania 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
$78.20 / $2,070.00 / $7,629.00
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$38.27 / $62.31 / $122.57
Capital Blue Cross
Facility/Professional
Facility
Modifier
Low / Median / High Price
$2,299.82 / $2,746.00 / $13,822.74
Capital Blue Cross
Facility/Professional
Professional
Modifier
Low / Median / High Price
$77.63 / $128.06 / $135.66
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$43.19 / $73.06 / $123.40
Emblem Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$94.17 / $121.08 / $125.34
Martin's Point
Facility/Professional
Facility
Modifier
Low / Median / High Price
$594.00 / $2,326.00 / $8,017.00
Martin's Point
Facility/Professional
Professional
Modifier
Low / Median / High Price
$39.52 / $70.58 / $293.51
Oscar Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$78.40 / $78.40 / $78.40
Priority Health
Facility/Professional
Facility
Modifier
Low / Median / High Price
$74.58 / $74.58 / $74.58
Priority Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$43.22 / $73.23 / $126.85
UPMC Health Plan
Facility/Professional
Facility
Modifier
Low / Median / High Price
$40.44 / $43.70 / $80.06
UPMC Health Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$41.88 / $62.11 / $85.85
United
Facility/Professional
Facility
Modifier
Low / Median / High Price
$144.00 / $674.00 / $4,300.00
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$66.62 / $84.04 / $146.78