go back

New Hampshire 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 / $64.51
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$51.00 / $51.00 / $61.20
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$51.00 / $51.00 / $51.00
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$48.12 / $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 / $74.02
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$51.00 / $51.00 / $101.36
Well Sense
Facility/Professional
Professional
Modifier
Low / Median / High Price
$17.80 / $54.23 / $83.19