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Montana 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
Professional
Modifier
Low / Median / High Price
$185.22 / $290.08 / $1,801.76
BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$47,000.00 / $77,999.99 / $94,999.99
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$347.55 / $347.55 / $347.55
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$295.42 / $388.65 / $537.37
Providence
Facility/Professional
Facility
Modifier
Low / Median / High Price
$198.26 / $329.43 / $527.09
Providence
Facility/Professional
Professional
Modifier
Low / Median / High Price
$295.42 / $418.15 / $657.17
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$508.09 / $567.82 / $626.55