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Massachusetts 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 / $51.00 / $51.00
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$51.00 / $51.00 / $53.04
AllWays Health Partners
Facility/Professional
Facility
Modifier
Low / Median / High Price
$53.55 / $156.16 / $231.33
AllWays Health Partners
Facility/Professional
Professional
Modifier
Low / Median / High Price
$51.00 / $51.00 / $231.33
BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$54.72 / $62.63 / $115.01
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$51.00 / $51.00 / $51.00
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$51.00 / $51.00 / $51.00
Fallon Health
Facility/Professional
Facility
Modifier
Low / Median / High Price
$52.02 / $80.58 / $8,090.00
Fallon Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$71.88 / $71.88 / $84.56
Harvard Pilgrim
Facility/Professional
Professional
Modifier
Low / Median / High Price
$51.00 / $51.00 / $51.00
Health New England
Facility/Professional
Facility
Modifier
Low / Median / High Price
$2,758.68 / $2,758.68 / $2,758.68
Mass General Brigham
Facility/Professional
Facility
Modifier
Low / Median / High Price
$75.00 / $75.00 / $231.33
Mass General Brigham
Facility/Professional
Professional
Modifier
Low / Median / High Price
$51.00 / $51.00 / $231.33
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$51.00 / $51.00 / $101.36