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Hawaii 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
Professional
Modifier
Low / Median / High Price
$26.94 / $26.94 / $27.21
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$26.94 / $30.88 / $36.33
HMSA
Facility/Professional
Professional
Modifier
Low / Median / High Price
$41.66 / $46.29 / $50.84
Kaiser Permanente
Facility/Professional
Professional
Modifier
Low / Median / High Price
$29.64 / $32.33 / $37.72
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$26.94 / $32.70 / $40.40