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Virginia 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 / $28.29 / $28.29
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$26.94 / $26.94 / $28.29
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$26.94 / $26.94 / $36.11
CareFirst
Facility/Professional
Professional
Modifier
Low / Median / High Price
$11.64 / $11.64 / $34.44
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
Kaiser Permanente
Facility/Professional
Professional
Modifier
Low / Median / High Price
$22.90 / $26.94 / $107.15
Medcost
Facility/Professional
Facility
Modifier
Low / Median / High Price
$26.94 / $27.75 / $45.53
Medcost
Facility/Professional
Professional
Modifier
Low / Median / High Price
$16.00 / $50.00 / $64.00
Sentara
Facility/Professional
Facility
Modifier
Low / Median / High Price
$26.09 / $31.31 / $77.52
Sentara
Facility/Professional
Professional
Modifier
Low / Median / High Price
$26.09 / $31.31 / $77.52
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$26.94 / $26.94 / $28.74