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South Carolina rates for HCPCS Q4105

Integra Dermal Regeneration Template (Drt) Or Or Integra Omnigraft Dermal Regeneration Matrix Per Square Centimeter (Desc Rvsd 1/1/17)

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$28.29 / $28.29 / $28.29
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$23.85 / $26.94 / $28.29
BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$29.00 / $38.67 / $63.11
BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$26.94 / $38.67 / $49.43
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$25.42 / $26.94 / $26.94
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$26.94 / $26.94 / $26.94
Medcost
Facility/Professional
Facility
Modifier
Low / Median / High Price
$11.87 / $28.29 / $81.59
Medcost
Facility/Professional
Professional
Modifier
Low / Median / High Price
$10.36 / $10.36 / $10.36
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$23.25 / $26.94 / $47.41
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$24.78 / $26.94 / $29.63