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Ohio 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 $31 · 10th–90th $26–$2750%20%10th90th$31Professionalmedian $27 · 10th–90th $26–$1260%50%10th90th$27$2.0$5.0$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 / $30.90
Aetna
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$25.70 / $25.70 / $30.90
Anthem BCBS
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$26.92 / $34.67 / $138.04
CareSource
Facility/Professional
Facility
Modifier
Typical Low / Median / Typical High
$26.92 / $26.92 / $26.92
CareSource
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$26.92 / $26.92 / $36.31
Cigna
Facility/Professional
Facility
Modifier
Typical Low / Median / Typical High
$239.88 / $269.15 / $416.87
Cigna
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$125.89 / $125.89 / $125.89
Medical Mutual of Ohio
Facility/Professional
Facility
Modifier
Typical Low / Median / Typical High
$25.70 / $25.70 / $26.92
Medical Mutual of Ohio
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$26.92 / $26.92 / $38.02
Molina
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$29.51 / $87.10 / $128.82
SummaCare
Facility/Professional
Facility
Modifier
Typical Low / Median / Typical High
$134.90 / $144.54 / $158.49
SummaCare
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$54.95 / $83.18 / $144.54
United
Facility/Professional
Facility
Modifier
Typical Low / Median / Typical High
$28.18 / $102.33 / $102.33
United
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$23.44 / $125.89 / $125.89