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Idaho 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
$53.76 / $53.76 / $53.76
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$51.00 / $56.10 / $63.75
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
Moda Health
Facility/Professional
Facility
Modifier
Low / Median / High Price
$13.86 / $56.10 / $71.81
Moda Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$51.00 / $51.00 / $63.75
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$30.00 / $77.17 / $97.09
Regence BlueShield
Facility/Professional
Professional
Modifier
Low / Median / High Price
$61.20 / $61.20 / $61.20
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$51.00 / $51.00 / $51.00