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Oregon 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 / $117.49 / $117.49
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$61.66 / $63.10 / $117.49
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$58.88 / $85.11 / $125.89
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$63.10 / $63.10 / $70.79
Kaiser Permanente
Facility/Professional
Professional
Modifier
Low / Median / High Price
$151.36 / $245.47 / $323.59
Moda Health
Facility/Professional
Facility
Modifier
Low / Median / High Price
$63.10 / $75.86 / $141.25
Moda Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$114.82 / $239.88 / $316.23
Pacific Source
Facility/Professional
Facility
Modifier
Low / Median / High Price
$60.26 / $63.10 / $93.33
Providence
Facility/Professional
Facility
Modifier
Low / Median / High Price
$63.10 / $74.13 / $181.97
Providence
Facility/Professional
Professional
Modifier
Low / Median / High Price
$74.13 / $125.89 / $151.36
Regence BlueShield
Facility/Professional
Professional
Modifier
Low / Median / High Price
$125.89 / $125.89 / $125.89
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$81.28 / $125.89 / $125.89