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Virginia 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 / $65.53 / $65.53
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$62.41 / $62.41 / $65.53
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$62.41 / $62.41 / $83.30
CareFirst
Facility/Professional
Professional
Modifier
Low / Median / High Price
$82.88 / $82.88 / $110.69
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
Kaiser Permanente
Facility/Professional
Professional
Modifier
Low / Median / High Price
$53.05 / $62.41 / $83.43
Medcost
Facility/Professional
Facility
Modifier
Low / Median / High Price
$62.41 / $65.53 / $105.47
Medcost
Facility/Professional
Professional
Modifier
Low / Median / High Price
$86.00 / $154.32 / $188.02
Sentara
Facility/Professional
Facility
Modifier
Low / Median / High Price
$59.81 / $71.77 / $92.63
Sentara
Facility/Professional
Professional
Modifier
Low / Median / High Price
$59.81 / $71.77 / $92.63
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$62.41 / $62.41 / $78.31