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Integra Bilayer Matrix Wound Dressing

Ohio rates for HCPCS Q4104

Integra bilayer matrix wound dressing (BMWD), per sq cm (add-on, list separately in addition to primary procedure)

Rates data updated July 2026.

Facilitymedian $102 · 10th–90th $51$3160%20%40%10th90th$102Professionalmedian $54 · 10th–90th $51$1260%50%10th90th$54$2.0$10.0$50.0$200.0$1.0K

Distribution of negotiated rates across all payers (price axis is log-scale). Facility and professional rates are different services and are charted separately. Need provider-level prices? Contact us.

Insurance Carrier
Aetna
Setting
Facility
Modifier
Global
Typical Low
$51.29
Median
$51.29
Typical High
$60.26
Aetna
Setting
Professional
Modifier
Global
Typical Low
$51.29
Median
$51.29
Typical High
$56.23
Anthem BCBS
Setting
Professional
Modifier
Global
Typical Low
$51.29
Median
$64.57
Typical High
$138.04
CareSource
Setting
Facility
Modifier
Global
Typical Low
$51.29
Median
$51.29
Typical High
$51.29
CareSource
Setting
Professional
Modifier
Global
Typical Low
$51.29
Median
$51.29
Typical High
$69.18
Cigna
Setting
Facility
Modifier
Global
Typical Low
$239.88
Median
$269.15
Typical High
$416.87
Cigna
Setting
Professional
Modifier
Global
Typical Low
$125.89
Median
$125.89
Typical High
$125.89
Medical Mutual of Ohio
Setting
Facility
Modifier
Global
Typical Low
$181.97
Median
$251.19
Typical High
$371.54
Medical Mutual of Ohio
Setting
Professional
Modifier
Global
Typical Low
$112.20
Median
$125.89
Typical High
$125.89
Molina
Setting
Professional
Modifier
Global
Typical Low
$56.23
Median
$91.20
Typical High
$128.82
SummaCare
Setting
Facility
Modifier
Global
Typical Low
$125.89
Median
$141.25
Typical High
$158.49
SummaCare
Setting
Professional
Modifier
Global
Typical Low
$60.26
Median
$83.18
Typical High
$165.96
United
Setting
Facility
Modifier
Global
Typical Low
$102.33
Median
$102.33
Typical High
$275.42
United
Setting
Professional
Modifier
Global
Typical Low
$102.33
Median
$125.89
Typical High
$125.89