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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)

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$59.16 / $59.16 / $1,815.70
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$51.00 / $56.10 / $63.75
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$58.01 / $69.20 / $79.58
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$51.00 / $51.00 / $51.00
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$41.04 / $44.86 / $60.00
Regence BlueShield
Facility/Professional
Professional
Modifier
Low / Median / High Price
$47.69 / $56.10 / $56.10
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$51.00 / $51.00 / $51.00