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Wisconsin rates for HCPCS Q4219

Surgigraft-Dual Per Square Centimeter

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$960.00 / $960.00 / $960.00
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$960.00 / $960.00 / $1,020.00
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$85.71 / $112.70 / $960.00
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,020.00 / $1,020.00 / $1,020.00
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,020.00 / $1,020.00 / $1,020.00
DeanCare
Facility/Professional
Facility
Modifier
Low / Median / High Price
$960.00 / $960.00 / $1,430.40
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$960.00 / $972.00 / $1,440.00
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$788.99 / $788.99 / $1,656.88
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$50.00 / $58.40 / $85.00
Prevea360
Facility/Professional
Facility
Modifier
Low / Median / High Price
$960.00 / $960.00 / $1,430.40
Quartz
Facility/Professional
Professional
Modifier
Low / Median / High Price
$5,900.00 / $5,900.00 / $5,900.00
Quartz
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,020.00 / $1,140.00 / $4,500.00
Quartz
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,020.00 / $1,272.00 / $4,560.00
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$788.99 / $788.99 / $946.79