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Idaho rates for HCPCS Q4122

DermACELL, DermACELL AWM or DermACELL AWM Porous, per sq cm (add-on, list separately in addition to primary procedure)

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$102.85 / $102.85 / $102.85
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$96.80 / $102.85 / $104.06
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$102.85 / $102.85 / $102.85
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$102.85 / $102.85 / $102.85
Moda Health
Facility/Professional
Facility
Modifier
Low / Median / High Price
$100.43 / $109.26 / $131.65
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$30.00 / $55.00 / $3,500.00
Regence BlueShield
Facility/Professional
Facility
Modifier
Low / Median / High Price
$43.21 / $43.21 / $53.03
Regence BlueShield
Facility/Professional
Professional
Modifier
Low / Median / High Price
$51.06 / $51.06 / $74.63
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$110.00 / $110.00 / $154.00