go back

Nebraska 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 / $26.09 / $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
$25.93 / $30.50 / $30.50
BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$28.05 / $29.53 / $30.50
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$21.27 / $23.39 / $26.94
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$26.94 / $30.20 / $45.42
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$26.09 / $44.09 / $56.76
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$23.25 / $26.09 / $119.05
Midlands
Facility/Professional
Facility
Modifier
Low / Median / High Price
$27.90 / $32.71 / $45.98
Midlands
Facility/Professional
Professional
Modifier
Low / Median / High Price
$17.19 / $34.52 / $65.22
Oscar Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$22.00 / $22.00 / $26.70
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$25.59 / $26.94 / $29.63