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New Hampshire rates for HCPCS Q4205

Membrane Graft or Membrane Wrap, per sq cm (add-on, list separately in addition to primary procedure)

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,190.44 / $1,190.44 / $1,428.53
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,237.28 / $1,237.28 / $1,428.53
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,237.28 / $1,237.28 / $1,237.28
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,167.25 / $1,237.28 / $1,237.28
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,237.28 / $1,237.28 / $1,237.28
Harvard Pilgrim
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,237.28 / $1,237.28 / $1,795.79
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,237.28 / $1,237.28 / $1,427.66
Well Sense
Facility/Professional
Professional
Modifier
Low / Median / High Price
$336.60 / $443.19 / $483.48