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Maine rates for HCPCS Q4107

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

Insurance Carrier
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$82.93 / $85.96 / $85.96
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$80.90 / $85.96 / $94.55
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$85.96 / $85.96 / $85.96
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$85.96 / $85.96 / $85.96
Harvard Pilgrim
Facility/Professional
Professional
Modifier
Low / Median / High Price
$92.59 / $92.59 / $92.59
Martin's Point
Facility/Professional
Professional
Modifier
Low / Median / High Price
$85.96 / $85.96 / $85.96
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$136.47 / $136.47 / $197.88