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Wyoming 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
$53.76 / $53.76 / $53.76
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$51.00 / $55.59 / $56.10
BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$68.81 / $80.95 / $80.95
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$48.12 / $48.12 / $48.12
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$51.00 / $72.17 / $72.17
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$51.00 / $51.00 / $51.00