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Maryland 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
$26.09 / $26.09 / $26.09
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$26.94 / $26.94 / $28.29
CareFirst
Facility/Professional
Professional
Modifier
Low / Median / High Price
$11.64 / $11.64 / $11.64
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$26.94 / $26.94 / $69.36
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$26.94 / $26.94 / $34.32
Kaiser Permanente
Facility/Professional
Professional
Modifier
Low / Median / High Price
$22.90 / $26.94 / $107.15
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$26.94 / $26.94 / $28.56
Wellpoint
Facility/Professional
Professional
Modifier
Low / Median / High Price
$30.28 / $30.28 / $35.29