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Montana 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
Professional
Modifier
Low / Median / High Price
$27.21 / $29.37 / $29.93
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$26.54 / $26.54 / $122.42
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$25.22 / $26.54 / $26.94
Providence
Facility/Professional
Facility
Modifier
Low / Median / High Price
$10.56 / $26.54 / $62.14
Providence
Facility/Professional
Professional
Modifier
Low / Median / High Price
$26.54 / $29.23 / $41.62
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$26.94 / $26.94 / $26.94