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Massachusetts 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 / $26.94 / $26.94
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$26.94 / $26.94 / $29.64
AllWays Health Partners
Facility/Professional
Facility
Modifier
Low / Median / High Price
$28.29 / $82.49 / $133.71
AllWays Health Partners
Facility/Professional
Professional
Modifier
Low / Median / High Price
$26.94 / $26.94 / $133.71
BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$28.91 / $33.08 / $60.75
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 / $26.94
Fallon Health
Facility/Professional
Facility
Modifier
Low / Median / High Price
$27.48 / $53.00 / $8,090.00
Fallon Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$33.61 / $33.61 / $39.54
Harvard Pilgrim
Facility/Professional
Professional
Modifier
Low / Median / High Price
$26.94 / $26.94 / $26.94
Health New England
Facility/Professional
Facility
Modifier
Low / Median / High Price
$12,744.44 / $12,744.44 / $12,744.44
Mass General Brigham
Facility/Professional
Facility
Modifier
Low / Median / High Price
$75.00 / $75.00 / $133.71
Mass General Brigham
Facility/Professional
Professional
Modifier
Low / Median / High Price
$26.94 / $26.94 / $133.71
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$26.94 / $26.94 / $51.99