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Louisiana rates for HCPCS Q4203

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

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,052.89 / $1,063.42 / $1,084.47
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,052.89 / $1,063.42 / $1,158.18
BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$330.20 / $330.20 / $495.30
BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$330.20 / $330.20 / $336.80
Christus
Facility/Professional
Facility
Modifier
Low / Median / High Price
$121.37 / $121.37 / $121.37
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$993.29 / $993.29 / $1,052.89
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,052.89 / $1,052.89 / $1,052.89
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$997.27 / $1,052.89 / $1,160.81