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Vermont 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
Professional
Modifier
Low / Median / High Price
$51.00 / $51.00 / $51.00
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$48.12 / $56.37 / $93.95
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$51.00 / $51.00 / $93.95
MVP Health Care
Facility/Professional
Facility
Modifier
Low / Median / High Price
$48.12 / $56.37 / $93.95
MVP Health Care
Facility/Professional
Professional
Modifier
Low / Median / High Price
$51.00 / $51.00 / $93.95
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$51.00 / $51.00 / $153.00