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Maine rates for HCPCS Q4102

Oasis wound matrix, per sq cm (add-on, list separately in addition to primary procedure)

Insurance Carrier
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$10.96 / $10.96 / $14.13
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$30.20 / $30.90 / $33.88
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$11.75 / $11.75 / $11.75
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$11.75 / $11.75 / $11.75
Harvard Pilgrim
Facility/Professional
Professional
Modifier
Low / Median / High Price
$11.75 / $11.75 / $14.45
Martin's Point
Facility/Professional
Professional
Modifier
Low / Median / High Price
$10.96 / $12.02 / $38.90
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$11.75 / $30.20 / $125.89