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North Dakota 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 / $29.93
BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$24.30 / $27.33 / $29.60
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$55.32 / $55.32 / $63.62
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$23.66 / $26.94 / $29.58
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$26.02 / $36.53 / $53.18
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$23.25 / $26.09 / $29.22
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$26.94 / $26.94 / $39.97