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Massachusetts 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
$1,047.13 / $1,047.13 / $1,047.13
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$912.01 / $1,047.13 / $1,148.15
AllWays Health Partners
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,862.09 / $1,862.09 / $1,862.09
AllWays Health Partners
Facility/Professional
Professional
Modifier
Low / Median / High Price
$125.89 / $125.89 / $1,548.82
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,047.13 / $1,047.13 / $1,047.13
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,047.13 / $1,047.13 / $1,047.13
Fallon Health
Facility/Professional
Facility
Modifier
Low / Median / High Price
$134.90 / $234.42 / $8,511.38
Fallon Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$181.97 / $181.97 / $213.80
Harvard Pilgrim
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,047.13 / $1,047.13 / $1,047.13
Mass General Brigham
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,862.09 / $1,862.09 / $1,862.09
Mass General Brigham
Facility/Professional
Professional
Modifier
Low / Median / High Price
$125.89 / $125.89 / $1,000.00
United
Facility/Professional
Facility
Modifier
Low / Median / High Price
$302.00 / $645.65 / $1,000.00
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$125.89 / $1,000.00 / $1,047.13