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New Mexico 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 $30 · 10th–90th $13–$1260%20%10th90th$30Professionalmedian $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
Facility
Modifier
Typical Low / Median / Typical High
$25.70 / $25.70 / $25.70
Aetna
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$25.70 / $26.92 / $33.11
Cigna
Facility/Professional
Facility
Modifier
Typical Low / Median / Typical High
$125.89 / $125.89 / $257.04
Cigna
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$125.89 / $125.89 / $125.89
Molina
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$30.20 / $34.67 / $64.57
Providence
Facility/Professional
Facility
Modifier
Typical Low / Median / Typical High
$12.30 / $29.51 / $125.89
Providence
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$40.74 / $125.89 / $125.89
United
Facility/Professional
Facility
Modifier
Typical Low / Median / Typical High
$23.44 / $23.44 / $120.23
United
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$23.44 / $125.89 / $125.89