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Michigan 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
$26.92 / $26.92 / $26.92
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$25.70 / $25.70 / $33.11
BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$6.31 / $6.31 / $6.31
BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$6.31 / $10.23 / $10.23
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$26.92 / $26.92 / $30.20
Health Alliance Plan
Facility/Professional
Facility
Modifier
Low / Median / High Price
$40.74 / $85.11 / $229.09
Health Alliance Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$25.70 / $85.11 / $138.04
Priority Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$25.12 / $26.92 / $26.92
United
Facility/Professional
Facility
Modifier
Low / Median / High Price
$38.02 / $38.02 / $120.23
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$23.44 / $67.61 / $125.89