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Alaska rates for HCPCS Q4104

Integra bilayer matrix wound dressing (BMWD), per sq cm (add-on, list separately in addition to primary procedure)

Insurance Carrier
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$94.87 / $94.87 / $94.87
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$51.00 / $51.00 / $51.00
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$51.00 / $51.00 / $72.17
Moda Health
Facility/Professional
Facility
Modifier
Low / Median / High Price
$53.76 / $94.87 / $132.82
Moda Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$51.00 / $51.00 / $66.30
Premera BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$47.61 / $107.38 / $168.74
Premera BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$63.66 / $84.37 / $92.04
Providence
Facility/Professional
Facility
Modifier
Low / Median / High Price
$51.00 / $94.87 / $145.66
Providence
Facility/Professional
Professional
Modifier
Low / Median / High Price
$51.00 / $61.69 / $87.40
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$76.50 / $76.50 / $153.00