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Illinois 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
$26.94 / $26.94 / $85.68
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$26.94 / $26.94 / $29.93
BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$24.00 / $67.25 / $437.59
BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$26.32 / $26.32 / $32.47
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 / $31.77
Hally Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$22.90 / $34.21 / $272.87
Hally Health
Facility/Professional
Facility
Modifier
Low / Median / High Price
$100.00 / $100.00 / $100.00
Hally Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$35.02 / $35.02 / $35.02
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$30.00 / $30.00 / $34.88
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$26.94 / $26.94 / $29.54