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Maine rates for HCPCS Q4204

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

Insurance Carrier
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$3,692.14 / $3,839.83 / $3,839.83
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$3,692.14 / $3,692.14 / $3,774.77
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$3,692.14 / $3,692.14 / $3,692.14
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$3,692.14 / $3,692.14 / $3,692.14
Harvard Pilgrim
Facility/Professional
Professional
Modifier
Low / Median / High Price
$3,692.14 / $3,692.14 / $3,692.14
Martin's Point
Facility/Professional
Professional
Modifier
Low / Median / High Price
$3,692.14 / $3,839.83 / $3,839.83
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$3,692.14 / $3,692.14 / $5,353.60