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Pennsylvania 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
$322.47 / $2,747.00 / $8,017.00
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$193.43 / $278.63 / $409.83
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
$334.16 / $549.29 / $593.72
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$209.40 / $326.48 / $536.04
Emblem Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$402.03 / $516.90 / $534.53
Martin's Point
Facility/Professional
Facility
Modifier
Low / Median / High Price
$918.00 / $3,389.00 / $8,017.00
Martin's Point
Facility/Professional
Professional
Modifier
Low / Median / High Price
$195.89 / $306.85 / $1,183.70
Oscar Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$319.80 / $319.80 / $331.50
Priority Health
Facility/Professional
Facility
Modifier
Low / Median / High Price
$378.97 / $378.97 / $378.97
Priority Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$219.26 / $330.46 / $564.05
UPMC Health Plan
Facility/Professional
Facility
Modifier
Low / Median / High Price
$198.46 / $218.67 / $335.34
UPMC Health Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$210.65 / $268.11 / $357.56
United
Facility/Professional
Facility
Modifier
Low / Median / High Price
$814.00 / $2,391.00 / $6,000.00
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$285.69 / $359.38 / $672.72