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California 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
$62.41 / $62.41 / $63.04
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$62.41 / $62.41 / $74.90
Anthem BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$58.29 / $69.40 / $117.42
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$59.81 / $64.89 / $168.59
Blue Shield
Facility/Professional
Facility
Modifier
Low / Median / High Price
$100.00 / $100.00 / $100.00
Blue Shield
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.70 / $1.00 / $2.50
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$58.88 / $58.88 / $62.41
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$62.41 / $62.41 / $76.55
Contra Costa Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$59.54 / $65.50 / $80.38
Kaiser Permanente
Facility/Professional
Professional
Modifier
Low / Median / High Price
$58.35 / $78.01 / $137.30
Lucent Health
Facility/Professional
Facility
Modifier
Low / Median / High Price
$97.50 / $262.88 / $286.27
Lucent Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$288.95 / $332.08 / $371.52
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$65.49 / $80.37 / $122.05
Providence
Facility/Professional
Facility
Modifier
Low / Median / High Price
$62.41 / $68.66 / $107.51
Providence
Facility/Professional
Professional
Modifier
Low / Median / High Price
$62.41 / $62.41 / $105.02
The Alliance
Facility/Professional
Professional
Modifier
Low / Median / High Price
$49.93 / $59.54 / $71.45
United
Facility/Professional
Facility
Modifier
Low / Median / High Price
$280.81 / $295.94 / $295.94
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$62.41 / $62.41 / $119.89