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Maine rates for HCPCS Q4254

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

Insurance Carrier
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$114.82 / $354.81 / $371.54
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$125.89 / $125.89 / $354.81
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$407.38 / $407.38 / $407.38
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$407.38 / $407.38 / $407.38
Harvard Pilgrim
Facility/Professional
Professional
Modifier
Low / Median / High Price
$354.81 / $354.81 / $363.08
Martin's Point
Facility/Professional
Professional
Modifier
Low / Median / High Price
$117.49 / $354.81 / $457.09
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$125.89 / $354.81 / $478.63