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Arkansas 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
Facility
Modifier
Low / Median / High Price
$61.20 / $61.20 / $61.20
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$51.00 / $53.55 / $61.20
BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$58.33 / $58.33 / $58.33
BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$51.67 / $58.33 / $58.33
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$21.80 / $51.00 / $51.00
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$51.00 / $51.00 / $55.33
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$48.45 / $51.00 / $58.14