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Arizona 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
$29.64 / $53.88 / $53.88
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$26.94 / $27.21 / $29.64
BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$18.75 / $44.30 / $109.56
BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$19.05 / $23.44 / $55.38
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$26.94 / $26.94 / $26.94
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$26.94 / $26.94 / $26.94
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$24.40 / $30.89 / $60.73
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$26.09 / $26.09 / $119.05
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$26.94 / $26.94 / $26.94