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New Hampshire rates for HCPCS Q4203

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

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$131.83 / $1,047.13 / $1,258.93
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,047.13 / $1,047.13 / $1,258.93
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$125.89 / $125.89 / $125.89
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,000.00 / $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 / $1,698.24
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$125.89 / $1,000.00 / $1,047.13
Well Sense
Facility/Professional
Facility
Modifier
Low / Median / High Price
$851.14 / $851.14 / $1,348.96