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Indiana 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
$60.41 / $63.04 / $63.04
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$62.41 / $62.41 / $63.04
Anthem BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$62.41 / $62.41 / $120.45
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$62.41 / $62.41 / $88.62
CareSource
Facility/Professional
Facility
Modifier
Low / Median / High Price
$62.41 / $62.41 / $93.62
CareSource
Facility/Professional
Professional
Modifier
Low / Median / High Price
$62.41 / $62.41 / $74.89
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 / $88.18
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$62.41 / $62.41 / $77.39