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Illinois 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 / $102.38
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$62.41 / $62.41 / $68.66
BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$244.30 / $373.29 / $1,849.83
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 / $81.92
Hally Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$53.05 / $87.37 / $174.88
Hally Health
Facility/Professional
Facility
Modifier
Low / Median / High Price
$100.00 / $100.00 / $100.00
Hally Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$81.13 / $81.13 / $81.13
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$30.00 / $40.00 / $93.05
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$62.41 / $62.41 / $70.52