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Indiana 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
$96.80 / $96.80 / $22,742.40
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$96.80 / $96.80 / $98.01
Anthem BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$40.21 / $40.21 / $77.61
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$40.21 / $40.21 / $64.33
CareSource
Facility/Professional
Facility
Modifier
Low / Median / High Price
$64.41 / $64.41 / $88.26
CareSource
Facility/Professional
Professional
Modifier
Low / Median / High Price
$64.41 / $77.29 / $96.61
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 / $121.00
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$110.00 / $110.00 / $136.40