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Hawaii 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
$51.29 / $51.29 / $56.23
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$44.67 / $51.29 / $63.10
HMSA
Facility/Professional
Professional
Modifier
Low / Median / High Price
$72.44 / $79.43 / $91.20
Kaiser Permanente
Facility/Professional
Professional
Modifier
Low / Median / High Price
$144.54 / $173.78 / $204.17
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$53.70 / $67.61 / $125.89