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Wisconsin rates for HCPCS 15278

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; 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
$45.14 / $109.87 / $1,894.00
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$45.14 / $79.81 / $189.97
Anthem BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,139.00 / $1,183.00 / $1,530.00
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$76.84 / $161.50 / $357.25
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$246.91 / $288.52 / $442.61
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$60.55 / $115.17 / $272.95
DeanCare
Facility/Professional
Facility
Modifier
Low / Median / High Price
$54.10 / $106.73 / $253.29
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$58.60 / $147.12 / $1,590.00
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$84.43 / $158.97 / $402.64
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$58.91 / $95.42 / $218.92
Prevea360
Facility/Professional
Facility
Modifier
Low / Median / High Price
$54.10 / $106.73 / $253.29
Quartz
Facility/Professional
Professional
Modifier
Low / Median / High Price
$124.72 / $187.74 / $305.07
Quartz
Facility/Professional
Facility
Modifier
Low / Median / High Price
$103.03 / $137.69 / $252.81
Quartz
Facility/Professional
Professional
Modifier
Low / Median / High Price
$67.95 / $224.24 / $5,990.92
Security Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$123.34 / $226.82 / $399.40
United
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,008.00 / $1,423.00 / $2,202.90
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$83.90 / $148.43 / $372.05