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Louisiana rates for HCPCS Q4253

Zenith Amniotic Membrane, per sq cm (add-on, list separately in addition to primary procedure)

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$75.79 / $76.55 / $78.06
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$75.79 / $76.55 / $83.37
BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$78.65 / $78.65 / $117.98
BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$78.65 / $78.65 / $80.22
Christus
Facility/Professional
Facility
Modifier
Low / Median / High Price
$121.37 / $121.37 / $121.37
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$71.50 / $71.50 / $75.79
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$75.79 / $75.79 / $75.79
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$72.01 / $75.79 / $102.00