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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
$75.86 / $75.86 / $128.82
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$75.86 / $125.89 / $181.97
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$75.86 / $75.86 / $75.86
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$75.86 / $75.86 / $75.86
Harvard Pilgrim
Facility/Professional
Professional
Modifier
Low / Median / High Price
$75.86 / $75.86 / $91.20
Martin's Point
Facility/Professional
Professional
Modifier
Low / Median / High Price
$75.86 / $75.86 / $616.60
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$75.86 / $125.89 / $954.99