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GRAFTJACKET

New Hampshire rates for HCPCS Q4107

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

Rates data updated July 2026.

Facilitymedian $102 · 10th–90th $85$2950%20%10th90th$102Professionalmedian $93 · 10th–90th $85$1260%20%40%10th90th$93$100.0$200.0$500.0

Distribution of negotiated rates across all payers (price axis is log-scale). Facility and professional rates are different services and are charted separately. Need provider-level prices? Contact us.

Insurance Carrier
Aetna
Setting
Facility
Modifier
Global
Typical Low
$85.11
Median
$85.11
Typical High
$131.83
Aetna
Setting
Professional
Modifier
Global
Typical Low
$69.18
Median
$85.11
Typical High
$120.23
Anthem BCBS
Setting
Professional
Modifier
Global
Typical Low
$85.11
Median
$85.11
Typical High
$97.72
Cigna
Setting
Facility
Modifier
Global
Typical Low
$144.54
Median
$251.19
Typical High
$338.84
Cigna
Setting
Professional
Modifier
Global
Typical Low
$125.89
Median
$125.89
Typical High
$125.89
Harvard Pilgrim
Setting
Professional
Modifier
Global
Typical Low
$93.33
Median
$93.33
Typical High
$151.36
United
Setting
Facility
Modifier
Global
Typical Low
$208.93
Median
$208.93
Typical High
$208.93
United
Setting
Professional
Modifier
Global
Typical Low
$93.33
Median
$100.00
Typical High
$125.89
Well Sense
Setting
Facility
Modifier
Global
Typical Low
$100.00
Median
$123.03
Typical High
$138.04