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Maine rates for HCPCS Q4253

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

Insurance Carrier
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$75.79 / $78.81 / $78.81
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$75.79 / $75.79 / $83.36
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$75.79 / $75.79 / $75.79
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$75.79 / $75.79 / $75.79
Harvard Pilgrim
Facility/Professional
Professional
Modifier
Low / Median / High Price
$75.79 / $75.79 / $75.79
Martin's Point
Facility/Professional
Professional
Modifier
Low / Median / High Price
$75.79 / $78.81 / $78.81
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$75.79 / $75.79 / $113.69