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Pennsylvania 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 $26–$4470%20%40%10th90th$32Professionalmedian $27 · 10th–90th $26–$1260%50%10th90th$27$1.0$10.0$100.0$1.0K$10.0K

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 / $26.92 / $45.71
Aetna
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$25.70 / $25.70 / $32.36
Capital Blue Cross
Facility/Professional
Facility
Modifier
Typical Low / Median / Typical High
$56.23 / $66.07 / $5,011.87
Capital Blue Cross
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$66.07 / $66.07 / $66.07
Cigna
Facility/Professional
Facility
Modifier
Typical Low / Median / Typical High
$125.89 / $446.68 / $478.63
Cigna
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$125.89 / $125.89 / $125.89
Emblem Health
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$67.61 / $67.61 / $162.18
Geisinger
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$11.75 / $131.83 / $199.53
Martin's Point
Facility/Professional
Facility
Modifier
Typical Low / Median / Typical High
$25.70 / $25.70 / $26.92
Martin's Point
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$25.70 / $25.70 / $28.18
Oscar Health
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$0.60 / $194.98 / $245.47
UPMC Health Plan
Facility/Professional
Facility
Modifier
Typical Low / Median / Typical High
$21.38 / $24.55 / $43.65
UPMC Health Plan
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$12.59 / $24.55 / $309.03
United
Facility/Professional
Facility
Modifier
Typical Low / Median / Typical High
$154.88 / $154.88 / $154.88
United
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$25.12 / $125.89 / $134.90