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Washington 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 $56 · 10th–90th $19–$3390%10%10th90th$56Professionalmedian $28 · 10th–90th $26–$1260%20%40%10th90th$28$10.0$20.0$50.0$100.0$200.0$500.0$1.0K

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
$28.84 / $281.84 / $338.84
Aetna
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$25.70 / $26.92 / $53.70
Asuris Northwest Health
Facility/Professional
Facility
Modifier
Typical Low / Median / Typical High
$15.14 / $125.89 / $125.89
Asuris Northwest Health
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$125.89 / $125.89 / $141.25
Cigna
Facility/Professional
Facility
Modifier
Typical Low / Median / Typical High
$120.23 / $169.82 / $562.34
Cigna
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$125.89 / $125.89 / $125.89
Kaiser Permanente
Facility/Professional
Facility
Modifier
Typical Low / Median / Typical High
$18.20 / $60.26 / $380.19
Kaiser Permanente
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$18.20 / $57.54 / $93.33
Molina
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$30.20 / $33.11 / $75.86
Pacific Source
Facility/Professional
Facility
Modifier
Typical Low / Median / Typical High
$25.12 / $26.92 / $30.90
Premera BCBS
Facility/Professional
Facility
Modifier
Typical Low / Median / Typical High
$9.77 / $13.18 / $67.61
Premera BCBS
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$32.36 / $39.81 / $39.81
Regence BlueShield
Facility/Professional
Facility
Modifier
Typical Low / Median / Typical High
$13.80 / $15.14 / $125.89
Regence BlueShield
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$123.03 / $125.89 / $141.25
United
Facility/Professional
Facility
Modifier
Typical Low / Median / Typical High
$23.44 / $102.33 / $102.33
United
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$23.44 / $125.89 / $125.89
Wellpoint
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$134.90 / $154.88 / $295.12