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Pennsylvania 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 / $63.10 / $107.15
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$61.66 / $63.10 / $87.10
Capital Blue Cross
Facility/Professional
Facility
Modifier
Low / Median / High Price
$69.18 / $81.28 / $5,011.87
Capital Blue Cross
Facility/Professional
Professional
Modifier
Low / Median / High Price
$81.28 / $81.28 / $81.28
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$63.10 / $63.10 / $63.10
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$63.10 / $63.10 / $64.57
Emblem Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$70.79 / $83.18 / $223.87
Geisinger
Facility/Professional
Professional
Modifier
Low / Median / High Price
$117.49 / $151.36 / $218.78
Martin's Point
Facility/Professional
Facility
Modifier
Low / Median / High Price
$61.66 / $63.10 / $107.15
Martin's Point
Facility/Professional
Professional
Modifier
Low / Median / High Price
$61.66 / $63.10 / $114.82
Oscar Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.60 / $194.98 / $245.47
UPMC Health Plan
Facility/Professional
Facility
Modifier
Low / Median / High Price
$72.44 / $72.44 / $102.33
UPMC Health Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$72.44 / $89.13 / $102.33
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$79.43 / $102.33 / $125.89