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Wisconsin 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
$34.67 / $87.10 / $3,162.28
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$38.02 / $69.18 / $234.42
Anthem BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,202.26 / $1,584.89 / $6,165.95
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$69.18 / $131.83 / $302.00
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$213.80 / $245.47 / $398.11
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$47.86 / $109.65 / $223.87
DeanCare
Facility/Professional
Facility
Modifier
Low / Median / High Price
$41.69 / $123.03 / $3,981.07
DeanCare
Facility/Professional
Professional
Modifier
Low / Median / High Price
$77.62 / $138.04 / $229.09
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$42.66 / $125.89 / $1,737.80
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$70.79 / $128.82 / $2,951.21
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$32.36 / $33.11 / $128.82
Quartz
Facility/Professional
Professional
Modifier
Low / Median / High Price
$75.86 / $138.04 / $288.40
Quartz
Facility/Professional
Facility
Modifier
Low / Median / High Price
$107.15 / $107.15 / $275.42
Quartz
Facility/Professional
Professional
Modifier
Low / Median / High Price
$47.86 / $89.13 / $3,548.13
Security Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$97.72 / $181.97 / $338.84
United
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,023.29 / $1,584.89 / $1,949.84
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$47.86 / $95.50 / $245.47