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New Hampshire rates for HCPCS Q4126

MemoDerm, DermaSpan, TranZgraft or InteguPly, per sq cm (add-on, list separately in addition to primary procedure)

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$59.81 / $59.81 / $71.77
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$62.41 / $62.41 / $71.77
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$62.41 / $62.41 / $62.41
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$58.88 / $62.41 / $62.41
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$62.41 / $62.41 / $62.41
Harvard Pilgrim
Facility/Professional
Professional
Modifier
Low / Median / High Price
$62.41 / $62.41 / $90.58
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$62.41 / $62.41 / $78.80