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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
$79.43 / $79.43 / $79.43
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$79.43 / $83.18 / $100.00
BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$97.72 / $97.72 / $97.72
BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$93.33 / $97.72 / $102.33
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$85.11 / $85.11 / $102.33
Health Alliance Plan
Facility/Professional
Facility
Modifier
Low / Median / High Price
$91.20 / $100.00 / $275.42
Health Alliance Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$79.43 / $100.00 / $147.91
Priority Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$85.11 / $85.11 / $97.72
United
Facility/Professional
Facility
Modifier
Low / Median / High Price
$138.04 / $138.04 / $223.87
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$125.89 / $138.04 / $138.04