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Indiana 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
$51.51 / $51.51 / $59.73
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$51.00 / $51.00 / $53.76
Ambetter
Facility/Professional
Professional
Modifier
Low / Median / High Price
$45.45 / $45.45 / $45.45
Anthem BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$51.00 / $51.00 / $98.43
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$51.00 / $51.00 / $72.42
CareSource
Facility/Professional
Facility
Modifier
Low / Median / High Price
$51.00 / $51.00 / $76.50
CareSource
Facility/Professional
Professional
Modifier
Low / Median / High Price
$51.00 / $51.00 / $61.20
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$51.00 / $51.00 / $51.00
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$40.26 / $51.00 / $64.44
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$51.00 / $51.00 / $68.13