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New Hampshire 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 $32 · 10th–90th $27–$2510%20%10th90th$32Professionalmedian $27 · 10th–90th $26–$790%50%10th90th$27$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
Facility
Modifier
Typical Low / Median / Typical High
$26.92 / $32.36 / $131.83
Aetna
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$25.70 / $26.92 / $33.11
Anthem BCBS
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$67.61 / $69.18 / $79.43
Cigna
Facility/Professional
Facility
Modifier
Typical Low / Median / Typical High
$144.54 / $251.19 / $338.84
Cigna
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$125.89 / $125.89 / $125.89
Harvard Pilgrim
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$26.92 / $26.92 / $50.12
United
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$26.92 / $31.62 / $125.89
Well Sense
Facility/Professional
Facility
Modifier
Typical Low / Median / Typical High
$81.28 / $81.28 / $112.20