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New Hampshire rates for HCPCS Q4107

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

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$85.96 / $85.96 / $103.15
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$81.92 / $85.96 / $85.96
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$80.90 / $85.96 / $85.96
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 / $134.38
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$116.00 / $136.47 / $136.47
Well Sense
Facility/Professional
Professional
Modifier
Low / Median / High Price
$96.15 / $115.38 / $169.61