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Oklahoma 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
$29.10 / $29.10 / $29.10
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$27.21 / $29.10 / $29.93
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 / $26.94
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$28.17 / $29.83 / $75.00
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$23.25 / $26.09 / $133.71
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$26.94 / $26.94 / $29.71