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Oklahoma 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
$1,137.11 / $1,137.11 / $1,137.11
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,052.89 / $1,137.11 / $1,137.11
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
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$871.37 / $988.13 / $1,345.74
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$300.18 / $871.37 / $1,325.33
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,000.25 / $1,052.89 / $1,161.02