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Louisiana 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
$51.00 / $51.51 / $52.53
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$51.00 / $51.51 / $56.10
BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$54.77 / $54.77 / $82.16
BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$54.77 / $54.77 / $55.87
Christus
Facility/Professional
Facility
Modifier
Low / Median / High Price
$40.00 / $40.00 / $121.37
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$48.12 / $48.12 / $51.00
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$51.00 / $51.00 / $51.00
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$48.46 / $51.00 / $62.22