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Utah rates for HCPCS Q4104

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

Facilitymedian $117 · 10th–90th $59–$1,8200%20%40%10th90th$117Professionalmedian $55 · 10th–90th $47–$1700%20%10th90th$55$20.0$50.0$100.0$200.0$500.0$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
Facility/Professional
Facility
Modifier
Typical Low / Median / Typical High
$58.88 / $1,819.70 / $1,819.70
Aetna
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$46.77 / $51.29 / $117.49
Cigna
Facility/Professional
Facility
Modifier
Typical Low / Median / Typical High
$60.26 / $70.79 / $144.54
Cigna
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$125.89 / $125.89 / $125.89
Molina
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$30.20 / $44.67 / $75.86
Regence BlueShield
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$112.20 / $141.25 / $162.18
Select Health
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$51.29 / $51.29 / $125.89
U of Utah Health Plan
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$38.90 / $144.54 / $245.47
United
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$120.23 / $125.89 / $125.89