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Arkansas rates for HCPCS Q4105

Integra dermal regeneration template (DRT) or Integra Omnigraft dermal regeneration matrix, per sq cm (add-on, list separately in addition to primary procedure)

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$32.33 / $32.33 / $32.33
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$26.94 / $29.93 / $32.33
BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$28.30 / $28.30 / $28.30
BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$24.13 / $28.30 / $28.30
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$14.69 / $26.94 / $26.94
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$26.94 / $26.94 / $29.23
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$25.59 / $26.94 / $30.71