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Virginia rates for HCPCS Q4253

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

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$75.79 / $79.58 / $79.58
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$75.79 / $75.79 / $79.58
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$614.79 / $614.79 / $820.63
CareFirst
Facility/Professional
Professional
Modifier
Low / Median / High Price
$31.91 / $31.91 / $346.80
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$71.50 / $71.50 / $75.79
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$75.79 / $75.79 / $75.79
Kaiser Permanente
Facility/Professional
Professional
Modifier
Low / Median / High Price
$64.42 / $75.79 / $1,029.51
Medcost
Facility/Professional
Facility
Modifier
Low / Median / High Price
$75.79 / $79.58 / $145.63
Medcost
Facility/Professional
Professional
Modifier
Low / Median / High Price
$161.00 / $829.00 / $1,129.80
Sentara
Facility/Professional
Facility
Modifier
Low / Median / High Price
$31.54 / $608.57 / $1,171.64
Sentara
Facility/Professional
Professional
Modifier
Low / Median / High Price
$31.54 / $608.57 / $1,171.64
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$75.79 / $75.79 / $95.12