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Montana 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)

Facilitymedian $26 · 10th–90th $22–$780%20%40%10th90th$26Professionalmedian $27 · 10th–90th $26–$1170%50%10th90th$27$10.0$20.0$50.0$100.0$200.0

Distribution of negotiated rates across all payers (price axis is log-scale). Facility and professional rates are different services and are charted separately. Need provider-level prices? Contact us.

Insurance Carrier
Aetna
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$25.70 / $25.70 / $112.20
Cigna
Facility/Professional
Facility
Modifier
Typical Low / Median / Typical High
$26.30 / $61.66 / $204.17
Cigna
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$26.30 / $125.89 / $181.97
MountainHealth Co-op
Facility/Professional
Facility
Modifier
Typical Low / Median / Typical High
$22.39 / $26.30 / $48.98
MountainHealth Co-op
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$22.39 / $26.30 / $48.98
Providence
Facility/Professional
Facility
Modifier
Typical Low / Median / Typical High
$16.22 / $27.54 / $181.97
Providence
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$26.30 / $67.61 / $125.89
United
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$125.89 / $125.89 / $125.89