go back

Texas 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 / $27.21
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$26.94 / $26.94 / $28.29
BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$46.46 / $117.59 / $234.62
BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$25.88 / $25.88 / $25.88
Christus
Facility/Professional
Facility
Modifier
Low / Median / High Price
$80.00 / $121.37 / $121.37
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
Lucent Health
Facility/Professional
Facility
Modifier
Low / Median / High Price
$75.00 / $133.71 / $133.71
Lucent Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$133.71 / $133.71 / $147.24
Moda Health
Facility/Professional
Facility
Modifier
Low / Median / High Price
$10.77 / $26.09 / $48.52
Moda Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$26.94 / $26.94 / $33.68
Oscar Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$22.00 / $26.70 / $205.54
Providence
Facility/Professional
Facility
Modifier
Low / Median / High Price
$11.29 / $26.94 / $48.52
Providence
Facility/Professional
Professional
Modifier
Low / Median / High Price
$26.94 / $26.94 / $35.59
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$26.94 / $26.94 / $27.29
Wellpoint
Facility/Professional
Professional
Modifier
Low / Median / High Price
$26.09 / $26.94 / $36.36