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New Hampshire rates for HCPCS Q4197

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

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$71.04 / $71.04 / $85.25
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$70.70 / $70.70 / $77.77
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$70.70 / $70.70 / $70.70
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$66.69 / $70.70 / $70.70
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$70.70 / $70.70 / $70.70
Harvard Pilgrim
Facility/Professional
Professional
Modifier
Low / Median / High Price
$70.70 / $70.70 / $102.61
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$70.70 / $70.70 / $169.68
Well Sense
Facility/Professional
Professional
Modifier
Low / Median / High Price
$255.00 / $280.50 / $357.00