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New Mexico 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
$1,047.13 / $1,047.13 / $1,148.15
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
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$44.67 / $208.93 / $446.68
Providence
Facility/Professional
Facility
Modifier
Low / Median / High Price
$190.55 / $1,047.13 / $1,819.70
Providence
Facility/Professional
Professional
Modifier
Low / Median / High Price
$125.89 / $125.89 / $371.54
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$125.89 / $302.00 / $1,000.00