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Maryland 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 / $51.00 / $53.55
CareFirst
Facility/Professional
Professional
Modifier
Low / Median / High Price
$22.31 / $22.31 / $22.31
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$51.00 / $51.00 / $68.81
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$51.00 / $51.00 / $64.95
Kaiser Permanente
Facility/Professional
Professional
Modifier
Low / Median / High Price
$43.35 / $51.00 / $107.33
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$49.79 / $51.00 / $53.81
Wellpoint
Facility/Professional
Professional
Modifier
Low / Median / High Price
$52.40 / $52.40 / $66.81