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Kentucky 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 / $26.94
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$26.94 / $26.94 / $27.75
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$26.94 / $26.94 / $26.94
CareSource
Facility/Professional
Facility
Modifier
Low / Median / High Price
$26.94 / $37.72 / $43.10
CareSource
Facility/Professional
Professional
Modifier
Low / Median / High Price
$26.94 / $29.63 / $43.10
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$26.94 / $85.00 / $85.00
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$25.44 / $26.94 / $38.11
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$23.25 / $26.09 / $30.23
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$26.94 / $26.94 / $34.21