go back

Maine rates for HCPCS Q4203

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

Insurance Carrier
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,047.13 / $1,047.13 / $1,096.48
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$125.89 / $125.89 / $1,047.13
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,047.13 / $1,047.13 / $1,047.13
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,047.13 / $1,047.13 / $1,047.13
Harvard Pilgrim
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,047.13 / $1,047.13 / $1,047.13
Martin's Point
Facility/Professional
Professional
Modifier
Low / Median / High Price
$275.42 / $1,047.13 / $1,348.96
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$125.89 / $1,000.00 / $1,047.13