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Maryland rates for HCPCS 15277

Application of skin substitute graft to face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits, total wound surface area greater than or equal to 100 sq cm; first 100 sq cm wound surface area, or 1% of body area of infants and children

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$4,155.39 / $4,155.39 / $4,155.39
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$203.66 / $290.08 / $596.38
CareFirst
Facility/Professional
Professional
Modifier
Low / Median / High Price
$225.42 / $225.42 / $286.27
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$209.75 / $321.83 / $565.96
Kaiser Permanente
Facility/Professional
Professional
Modifier
Low / Median / High Price
$345.57 / $433.82 / $796.04
United
Facility/Professional
Facility
Modifier
Low / Median / High Price
$450.00 / $450.00 / $450.00
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$267.14 / $363.11 / $745.08
Wellpoint
Facility/Professional
Professional
Modifier
Low / Median / High Price
$239.16 / $260.27 / $406.49