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North Dakota 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
$51.29 / $51.29 / $51.29
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$51.29 / $51.29 / $61.66
BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$53.70 / $61.66 / $77.62
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$79.43 / $79.43 / $91.20
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$51.29 / $51.29 / $64.57
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$48.98 / $53.70 / $91.20
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$50.12 / $53.70 / $60.26
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$67.61 / $107.15 / $138.04