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New Hampshire rates for HCPCS Q4105

Integra Dermal Regeneration Template (Drt) Or Or Integra Omnigraft Dermal Regeneration Matrix Per Square Centimeter (Desc Rvsd 1/1/17)

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$26.09 / $26.09 / $31.31
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$26.94 / $26.94 / $29.64
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$26.94 / $26.94 / $26.94
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$25.42 / $26.94 / $26.94
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$26.94 / $26.94 / $26.94
Harvard Pilgrim
Facility/Professional
Professional
Modifier
Low / Median / High Price
$26.94 / $26.94 / $39.10
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$26.94 / $26.94 / $64.66
Well Sense
Facility/Professional
Professional
Modifier
Low / Median / High Price
$49.15 / $54.07 / $68.81