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Vermont 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
Professional
Modifier
Low / Median / High Price
$26.94 / $26.94 / $29.93
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$25.42 / $26.32 / $43.86
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$26.94 / $26.94 / $43.86
MVP Health Care
Facility/Professional
Facility
Modifier
Low / Median / High Price
$25.42 / $26.32 / $43.86
MVP Health Care
Facility/Professional
Professional
Modifier
Low / Median / High Price
$26.94 / $26.94 / $43.86
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$26.94 / $26.94 / $80.81