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Idaho 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
$26.09 / $26.09 / $26.09
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$26.09 / $29.64 / $33.68
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$25.42 / $26.94 / $26.94
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$26.94 / $26.94 / $26.94
Moda Health
Facility/Professional
Facility
Modifier
Low / Median / High Price
$13.59 / $29.64 / $37.94
Moda Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$26.94 / $26.94 / $33.68
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$30.00 / $40.69 / $55.00
Regence BlueShield
Facility/Professional
Professional
Modifier
Low / Median / High Price
$32.33 / $32.33 / $32.33
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$26.94 / $26.94 / $26.94