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Virginia 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 / $53.55 / $5,540.25
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$51.00 / $51.00 / $53.55
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$51.00 / $51.00 / $68.36
CareFirst
Facility/Professional
Professional
Modifier
Low / Median / High Price
$22.31 / $22.31 / $67.73
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
Kaiser Permanente
Facility/Professional
Professional
Modifier
Low / Median / High Price
$43.35 / $51.00 / $107.33
Medcost
Facility/Professional
Facility
Modifier
Low / Median / High Price
$51.00 / $51.00 / $81.56
Medcost
Facility/Professional
Professional
Modifier
Low / Median / High Price
$23.00 / $70.55 / $118.87
Sentara
Facility/Professional
Facility
Modifier
Low / Median / High Price
$53.76 / $64.51 / $80.64
Sentara
Facility/Professional
Professional
Modifier
Low / Median / High Price
$53.76 / $64.51 / $80.64
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$49.79 / $51.00 / $55.76