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Arizona rates for HCPCS Q4126

MemoDerm, DermaSpan, TranZgraft or InteguPly, per sq cm (add-on, list separately in addition to primary procedure)

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$68.66 / $68.66 / $68.66
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$62.41 / $63.04 / $68.66
BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$51.05 / $120.60 / $298.25
BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$51.84 / $63.81 / $150.75
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$62.41 / $62.41 / $62.41
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$62.41 / $62.41 / $62.41
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$58.34 / $70.01 / $133.55
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$59.81 / $59.81 / $129.79
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$62.41 / $62.41 / $62.41