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Utah 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
$31.26 / $31.26 / $31.26
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$26.94 / $29.93 / $33.68
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$27.08 / $37.06 / $45.98
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$26.94 / $26.94 / $26.94
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$25.50 / $27.87 / $60.00
Regence BlueShield
Facility/Professional
Professional
Modifier
Low / Median / High Price
$26.68 / $29.64 / $29.64
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$26.94 / $26.94 / $26.94