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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
$1,148.15 / $1,148.15 / $1,148.15
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
$1,000.00 / $1,000.00 / $1,047.13
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,047.13 / $1,047.13 / $1,047.13
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$851.14 / $954.99 / $1,513.56
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$302.00 / $870.96 / $1,230.27
United
Facility/Professional
Facility
Modifier
Low / Median / High Price
$302.00 / $302.00 / $302.00
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$125.89 / $302.00 / $1,000.00