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Virginia 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 / $1,105.53 / $1,105.53
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,052.89 / $1,052.89 / $1,105.53
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,052.89 / $1,052.89 / $1,411.29
CareFirst
Facility/Professional
Professional
Modifier
Low / Median / High Price
$277.79 / $277.79 / $277.79
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
Kaiser Permanente
Facility/Professional
Professional
Modifier
Low / Median / High Price
$894.96 / $897.54 / $1,052.89
Medcost
Facility/Professional
Facility
Modifier
Low / Median / High Price
$998.00 / $1,052.89 / $1,683.72
Medcost
Facility/Professional
Professional
Modifier
Low / Median / High Price
$306.89 / $391.00 / $496.18
Sentara
Facility/Professional
Facility
Modifier
Low / Median / High Price
$280.61 / $321.95 / $614.39
Sentara
Facility/Professional
Professional
Modifier
Low / Median / High Price
$295.38 / $321.95 / $614.39
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,021.30 / $1,052.89 / $1,105.53