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New Hampshire rates for HCPCS Q4103

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

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$12.38 / $12.38 / $14.86
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$12.49 / $12.49 / $14.86
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$12.49 / $12.49 / $12.49
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$11.78 / $12.49 / $12.49
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$12.49 / $12.49 / $12.49
Harvard Pilgrim
Facility/Professional
Professional
Modifier
Low / Median / High Price
$12.49 / $12.49 / $18.13
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$12.49 / $12.49 / $13.76
Well Sense
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1.58 / $1.74 / $2.21