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Louisiana 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 / $63.04 / $64.29
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$62.41 / $63.04 / $68.66
BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$69.63 / $69.63 / $104.45
BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$69.63 / $69.63 / $71.02
Christus
Facility/Professional
Facility
Modifier
Low / Median / High Price
$121.37 / $121.37 / $121.37
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 / $62.41
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$59.30 / $62.41 / $78.01