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Wisconsin 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
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$74.13 / $117.49 / $245.47
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$85.11 / $186.21 / $323.59
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$85.11 / $114.82 / $239.88
DeanCare
Facility/Professional
Facility
Modifier
Low / Median / High Price
$81.28 / $85.11 / $144.54
DeanCare
Facility/Professional
Professional
Modifier
Low / Median / High Price
$204.17 / $204.17 / $204.17
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$81.28 / $93.33 / $173.78
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$138.04 / $138.04 / $851.14
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$32.36 / $33.11 / $70.79
Quartz
Facility/Professional
Professional
Modifier
Low / Median / High Price
$141.25 / $295.12 / $416.87
Quartz
Facility/Professional
Facility
Modifier
Low / Median / High Price
$85.11 / $85.11 / $302.00
Quartz
Facility/Professional
Professional
Modifier
Low / Median / High Price
$85.11 / $87.10 / $851.14
Security Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$147.91 / $147.91 / $147.91
Security Health
Facility/Professional
Facility
Modifier
Low / Median / High Price
$257.04 / $257.04 / $380.19
Security Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$97.72 / $125.89 / $257.04
United
Facility/Professional
Facility
Modifier
Low / Median / High Price
$138.04 / $138.04 / $138.04
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$125.89 / $138.04 / $138.04