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Missouri 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 / $101.13 / $106.19
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$80.90 / $80.90 / $85.96
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$77.56 / $95.56 / $114.74
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$85.96 / $85.96 / $85.96
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$85.96 / $85.96 / $85.96
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$80.90 / $106.00 / $195.78
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$133.74 / $136.47 / $844.00
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$122.82 / $136.47 / $156.94