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Virginia rates for HCPCS Q4204

XWRAP, per sq cm (add-on, list separately in addition to primary procedure)

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$3,692.14 / $3,876.75 / $3,876.75
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$3,692.14 / $3,692.14 / $3,876.75
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$3,692.14 / $3,692.14 / $4,948.93
CareFirst
Facility/Professional
Professional
Modifier
Low / Median / High Price
$3,692.14 / $3,692.14 / $3,692.14
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$3,483.15 / $3,483.15 / $3,692.14
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$3,692.14 / $3,692.14 / $3,692.14
Kaiser Permanente
Facility/Professional
Professional
Modifier
Low / Median / High Price
$3,138.32 / $3,480.61 / $3,692.14
Medcost
Facility/Professional
Facility
Modifier
Low / Median / High Price
$3,420.00 / $3,692.14 / $5,904.29
Medcost
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,653.00 / $3,420.00 / $3,420.00
Sentara
Facility/Professional
Facility
Modifier
Low / Median / High Price
$2,941.40 / $3,294.37 / $5,594.15
Sentara
Facility/Professional
Professional
Modifier
Low / Median / High Price
$2,941.40 / $3,294.37 / $5,594.15
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$3,632.51 / $3,692.14 / $3,917.36