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Ohio 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 / $66.00
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$51.00 / $51.00 / $52.53
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$51.00 / $58.14 / $99.02
CareSource
Facility/Professional
Facility
Modifier
Low / Median / High Price
$51.00 / $51.00 / $77.01
CareSource
Facility/Professional
Professional
Modifier
Low / Median / High Price
$51.00 / $51.00 / $68.84
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 / $72.17
Medical Mutual of Ohio
Facility/Professional
Facility
Modifier
Low / Median / High Price
$85.00 / $85.00 / $196.68
Medical Mutual of Ohio
Facility/Professional
Professional
Modifier
Low / Median / High Price
$51.00 / $51.00 / $80.95
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$51.00 / $62.23 / $75.26
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$49.79 / $51.00 / $63.29