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West 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
$37.63 / $51.51 / $51.51
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$51.00 / $51.51 / $53.55
CareSource
Facility/Professional
Facility
Modifier
Low / Median / High Price
$51.00 / $51.00 / $76.50
CareSource
Facility/Professional
Professional
Modifier
Low / Median / High Price
$51.00 / $51.00 / $118.24
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$48.12 / $85.00 / $85.00
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$51.00 / $51.00 / $51.00
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$49.47 / $51.00 / $119.25