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Louisiana rates for HCPCS Q4105

Integra Dermal Regeneration Template (Drt) Or Or Integra Omnigraft Dermal Regeneration Matrix Per Square Centimeter (Desc Rvsd 1/1/17)

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$26.94 / $27.21 / $27.75
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$26.94 / $27.21 / $29.64
BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$25.58 / $25.58 / $38.36
BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$25.58 / $25.58 / $26.09
Christus
Facility/Professional
Facility
Modifier
Low / Median / High Price
$40.00 / $40.00 / $121.37
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$25.42 / $25.42 / $26.94
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$26.94 / $26.94 / $26.94
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$25.60 / $26.94 / $32.86