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Michigan rates for HCPCS Q4107

GRAFTJACKET, per sq cm (add-on, list separately in addition to primary procedure)

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$80.90 / $80.90 / $80.90
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$80.90 / $80.90 / $85.96
BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$100.49 / $155.21 / $309.38
BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$92.53 / $101.30 / $131.49
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$85.96 / $85.96 / $114.03
Health Alliance Plan
Facility/Professional
Facility
Modifier
Low / Median / High Price
$80.90 / $101.13 / $101.13
Health Alliance Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$80.90 / $101.13 / $121.35
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$75.00 / $75.00 / $1,500.00
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$136.47 / $136.47 / $147.09