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Washington rates for HCPCS Q4219

Surgigraft-Dual Per Square Centimeter

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,020.00 / $1,020.00 / $1,020.00
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$960.00 / $1,020.00 / $1,020.00
Asuris Northwest Health
Facility/Professional
Facility
Modifier
Low / Median / High Price
$996.00 / $1,140.00 / $4,500.00
Asuris Northwest Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$996.00 / $4,560.00 / $5,400.00
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,020.00 / $1,020.00 / $2,040.00
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,020.00 / $1,020.00 / $1,020.00
Kaiser Permanente
Facility/Professional
Professional
Modifier
Low / Median / High Price
$12.82 / $12.82 / $12.82
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$50.00 / $50.00 / $75.00
Pacific Source
Facility/Professional
Facility
Modifier
Low / Median / High Price
$79,999.20 / $79,999.20 / $79,999.20
Premera BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$996.00 / $996.00 / $1,020.00
Premera BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$924.00 / $1,020.00 / $1,080.00
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$788.99 / $788.99 / $946.79
Wellpoint
Facility/Professional
Professional
Modifier
Low / Median / High Price
$100.84 / $100.84 / $100.84