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Oregon 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 / $53.76
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$51.00 / $51.00 / $59.16
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$48.12 / $74.15 / $99.58
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$51.00 / $51.00 / $60.14
Kaiser Permanente
Facility/Professional
Professional
Modifier
Low / Median / High Price
$105.29 / $130.93 / $150.06
Moda Health
Facility/Professional
Facility
Modifier
Low / Median / High Price
$22.77 / $53.55 / $96.90
Moda Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$51.00 / $54.06 / $63.75
Pacific Source
Facility/Professional
Facility
Modifier
Low / Median / High Price
$49.53 / $52.93 / $106.08
Providence
Facility/Professional
Facility
Modifier
Low / Median / High Price
$27.26 / $56.10 / $98.70
Providence
Facility/Professional
Professional
Modifier
Low / Median / High Price
$51.00 / $61.69 / $66.81
Regence BlueShield
Facility/Professional
Professional
Modifier
Low / Median / High Price
$48.45 / $51.00 / $51.00
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$51.00 / $51.00 / $58.65