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Oklahoma 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
$55.08 / $55.08 / $55.08
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$51.51 / $55.08 / $55.08
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 / $51.00
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$47.12 / $58.06 / $81.28
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$48.88 / $53.76 / $231.33
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$49.79 / $51.00 / $56.97