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Maine rates for HCPCS Q4133

Grafix PRIME, GrafixPL PRIME, Stravix and StravixPL, per sq cm (add-on, list separately in addition to primary procedure)

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,416.69 / $1,416.69 / $1,823.65
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$138.74 / $140.12 / $208.11
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$138.74 / $138.74 / $138.74
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$138.74 / $138.74 / $138.74
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$138.74 / $138.74 / $138.74
Harvard Pilgrim
Facility/Professional
Professional
Modifier
Low / Median / High Price
$138.74 / $138.74 / $138.74
Martin's Point
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,416.69 / $1,416.69 / $1,823.65
Martin's Point
Facility/Professional
Professional
Modifier
Low / Median / High Price
$138.74 / $144.29 / $242.79
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$138.74 / $138.74 / $208.11