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Indiana 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
$26.35 / $27.21 / $27.21
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$26.94 / $26.94 / $27.21
Anthem BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$26.94 / $26.94 / $51.99
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$26.94 / $26.94 / $38.25
CareSource
Facility/Professional
Facility
Modifier
Low / Median / High Price
$26.94 / $26.94 / $41.76
CareSource
Facility/Professional
Professional
Modifier
Low / Median / High Price
$26.94 / $26.94 / $32.33
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 / $33.22
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$26.94 / $26.94 / $35.99