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Arizona 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
$60.74 / $70.58 / $102.00
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$51.00 / $51.51 / $56.10
BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$40.15 / $94.86 / $234.59
BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$40.78 / $50.19 / $118.58
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$48.12 / $51.00 / $51.00
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$51.00 / $51.00 / $51.00
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$35.54 / $59.13 / $120.03
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$53.76 / $53.76 / $156.66
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$49.79 / $51.00 / $51.00