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Missouri 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
$52.53 / $80.95 / $85.00
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$51.00 / $52.02 / $61.20
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$13.49 / $19.10 / $51.00
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 / $64.95
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$53.76 / $69.90 / $134.00
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$49.79 / $53.76 / $231.33
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$49.79 / $51.00 / $60.69