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New Hampshire 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
$136.18 / $136.18 / $163.41
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$138.74 / $138.74 / $152.61
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
$130.88 / $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 / $201.37
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$138.74 / $138.74 / $332.98
Well Sense
Facility/Professional
Professional
Modifier
Low / Median / High Price
$211.80 / $264.75 / $400.16