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Maine 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
Professional
Modifier
Low / Median / High Price
$51.00 / $53.04 / $53.04
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$51.00 / $51.00 / $53.76
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
Harvard Pilgrim
Facility/Professional
Professional
Modifier
Low / Median / High Price
$51.00 / $51.00 / $51.00
Martin's Point
Facility/Professional
Professional
Modifier
Low / Median / High Price
$51.00 / $53.04 / $53.04
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$51.00 / $51.00 / $73.95