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Missouri 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
$61.66 / $64.57 / $102.33
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$61.66 / $63.10 / $97.72
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$97.72 / $109.65 / $134.90
BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$123.03 / $144.54 / $190.55
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$58.88 / $63.10 / $63.10
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$63.10 / $63.10 / $67.61
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$61.66 / $85.11 / $173.78
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$53.70 / $60.26 / $331.13
United
Facility/Professional
Facility
Modifier
Low / Median / High Price
$85.11 / $85.11 / $100.00
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$63.10 / $81.28 / $125.89