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New Mexico 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
$51.00 / $51.00 / $51.00
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$51.00 / $51.51 / $64.77
BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$95.74 / $221.45 / $384.78
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
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$49.79 / $52.40 / $81.16
Providence
Facility/Professional
Facility
Modifier
Low / Median / High Price
$12.26 / $51.00 / $56.10
Providence
Facility/Professional
Professional
Modifier
Low / Median / High Price
$51.00 / $51.00 / $62.66
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$49.79 / $51.00 / $51.00