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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
$18.26 / $27.21 / $27.21
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$26.94 / $27.21 / $28.29
CareSource
Facility/Professional
Facility
Modifier
Low / Median / High Price
$26.94 / $26.94 / $40.40
CareSource
Facility/Professional
Professional
Modifier
Low / Median / High Price
$26.94 / $26.94 / $62.48
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$25.42 / $85.00 / $85.00
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$26.94 / $26.94 / $26.94
United
Facility/Professional
Facility
Modifier
Low / Median / High Price
$43.05 / $43.05 / $43.05
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$26.94 / $26.94 / $119.05