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Utah 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 $31–$410%50%90th$31Professionalmedian $29 · 10th–90th $26–$1260%20%10th90th$29$20.0$50.0$100.0$200.0$500.0

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

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Typical Low / Median / Typical High
$30.90 / $30.90 / $30.90
Aetna
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$22.91 / $26.92 / $112.20
Cigna
Facility/Professional
Facility
Modifier
Typical Low / Median / Typical High
$31.62 / $35.48 / $144.54
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
$25.70 / $30.20 / $75.86
Regence BlueShield
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$112.20 / $141.25 / $162.18
Select Health
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$25.70 / $25.70 / $120.23
U of Utah Health Plan
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$33.88 / $144.54 / $245.47
United
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$125.89 / $125.89 / $125.89