go back

Minnesota 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 / $29.64
BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1.00 / $30.98 / $54.54
BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$20.87 / $25.31 / $26.09
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$53.03 / $97.45 / $136.97
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$23.90 / $29.58 / $35.97
Health Partners
Facility/Professional
Facility
Modifier
Low / Median / High Price
$47.10 / $89.31 / $123.44
Health Partners
Facility/Professional
Professional
Modifier
Low / Median / High Price
$23.66 / $23.66 / $32.18
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$16.36 / $26.09 / $57.75
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$26.09 / $26.09 / $59.85
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$26.94 / $26.94 / $48.84