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New Mexico 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
$25.70 / $25.70 / $25.70
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$25.70 / $25.70 / $33.11
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$26.92 / $26.92 / $26.92
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$26.92 / $26.92 / $26.92
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$30.20 / $34.67 / $64.57
Providence
Facility/Professional
Facility
Modifier
Low / Median / High Price
$12.30 / $29.51 / $125.89
Providence
Facility/Professional
Professional
Modifier
Low / Median / High Price
$40.74 / $125.89 / $125.89
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$23.44 / $67.61 / $125.89