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Missouri 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 / $81.59 / $348.00
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$26.94 / $27.48 / $32.33
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$11.87 / $16.50 / $41.77
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 / $34.32
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$26.35 / $38.29 / $75.00
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$23.61 / $26.09 / $133.71
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$26.94 / $26.94 / $32.95