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Kansas 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
$81.59 / $81.59 / $81.59
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$26.94 / $29.10 / $81.59
BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$62.25 / $62.25 / $62.25
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$15.00 / $17.00 / $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
$26.61 / $37.61 / $72.86
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$26.09 / $26.09 / $133.71
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$26.94 / $26.94 / $39.06