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Missouri 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 / $127.05 / $965.16
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$96.80 / $96.80 / $102.85
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$41.28 / $41.29 / $110.00
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
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$96.80 / $121.00 / $264.26
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$110.00 / $110.00 / $459.80
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$110.00 / $110.00 / $127.27