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Oklahoma rates for HCPCS Q4107

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

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$81.92 / $81.92 / $81.92
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$81.92 / $81.92 / $83.94
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$85.96 / $85.96 / $85.96
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$85.96 / $85.96 / $85.96
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$81.92 / $92.59 / $128.08
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$101.13 / $136.47 / $844.00
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$131.15 / $136.47 / $150.49