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Maine rates for HCPCS Q4248

Dermacyte Amniotic Membrane Allograft, per sq cm (add-on, list separately in addition to primary procedure)

Insurance Carrier
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$549.54 / $549.54 / $660.69
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$125.89 / $125.89 / $549.54
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$549.54 / $549.54 / $549.54
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$549.54 / $549.54 / $549.54
Harvard Pilgrim
Facility/Professional
Professional
Modifier
Low / Median / High Price
$549.54 / $549.54 / $562.34
Martin's Point
Facility/Professional
Professional
Modifier
Low / Median / High Price
$549.54 / $549.54 / $1,819.70
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$125.89 / $549.54 / $2,691.53