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New Hampshire rates for HCPCS Q4124

OASIS ultra tri-layer wound matrix, per sq cm (add-on, list separately in addition to primary procedure)

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$2.48 / $2.48 / $2.98
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$2.49 / $2.49 / $2.98
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$2.49 / $2.49 / $2.49
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$2.35 / $2.49 / $2.49
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$2.49 / $2.49 / $2.49
Harvard Pilgrim
Facility/Professional
Professional
Modifier
Low / Median / High Price
$2.49 / $2.49 / $3.61
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$2.49 / $2.49 / $5.98
Well Sense
Facility/Professional
Professional
Modifier
Low / Median / High Price
$12.75 / $14.03 / $17.85