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Washington 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
$81.13 / $193.36 / $14,464.32
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$38.27 / $66.06 / $129.69
Asuris Northwest Health
Facility/Professional
Facility
Modifier
Low / Median / High Price
$55.00 / $113.70 / $731.93
Asuris Northwest Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$64.31 / $133.55 / $3,377.81
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$644.92 / $1,110.00 / $1,110.00
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$56.19 / $98.63 / $213.77
Kaiser Permanente
Facility/Professional
Facility
Modifier
Low / Median / High Price
$59.40 / $101.01 / $185.23
Kaiser Permanente
Facility/Professional
Professional
Modifier
Low / Median / High Price
$62.50 / $104.03 / $195.99
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$18.01 / $99.99 / $175.76
Pacific Source
Facility/Professional
Facility
Modifier
Low / Median / High Price
$89.11 / $139.40 / $162.81
Premera BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$111.05 / $111.05 / $113.70
Premera BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$62.09 / $114.92 / $203.56
Regence BlueShield
Facility/Professional
Facility
Modifier
Low / Median / High Price
$580.97 / $580.97 / $731.93
Regence BlueShield
Facility/Professional
Professional
Modifier
Low / Median / High Price
$61.91 / $114.61 / $188.08
United
Facility/Professional
Facility
Modifier
Low / Median / High Price
$140.00 / $588.00 / $5,793.00
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$94.92 / $112.43 / $239.44
Wellpoint
Facility/Professional
Professional
Modifier
Low / Median / High Price
$45.22 / $45.22 / $87.44