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West 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
$26.92 / $77.62 / $77.62
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$25.70 / $25.70 / $32.36
CareSource
Facility/Professional
Facility
Modifier
Low / Median / High Price
$26.92 / $26.92 / $26.92
CareSource
Facility/Professional
Professional
Modifier
Low / Median / High Price
$26.92 / $26.92 / $26.92
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$25.70 / $85.11 / $85.11
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$26.92 / $26.92 / $114.82
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$67.61 / $120.23 / $125.89