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Wisconsin 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 $28 · 10th–90th $26–$1350%20%40%10th90th$28Professionalmedian $28 · 10th–90th $26–$1260%50%10th90th$28$5.0$20.0$100.0$500.0$2.0K

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
$26.92 / $26.92 / $26.92
Aetna
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$25.70 / $25.70 / $28.84
Anthem BCBS
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$36.31 / $67.61 / $97.72
Cigna
Facility/Professional
Facility
Modifier
Typical Low / Median / Typical High
$46.77 / $87.10 / $199.53
Cigna
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$23.44 / $69.18 / $125.89
DeanCare
Facility/Professional
Facility
Modifier
Typical Low / Median / Typical High
$26.92 / $27.54 / $58.88
DeanCare
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$25.12 / $25.12 / $29.51
Medica
Facility/Professional
Facility
Modifier
Typical Low / Median / Typical High
$26.30 / $26.92 / $75.86
Medica
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$26.30 / $26.30 / $120.23
Molina
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$32.36 / $33.11 / $70.79
Network Health
Facility/Professional
Facility
Modifier
Typical Low / Median / Typical High
$26.92 / $26.92 / $31.62
Network Health
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$30.90 / $32.36 / $54.95
Quartz
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$107.15 / $229.09 / $416.87
Quartz
Facility/Professional
Facility
Modifier
Typical Low / Median / Typical High
$26.92 / $85.11 / $134.90
Quartz
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$26.92 / $28.18 / $134.90
Security Health
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$36.31 / $44.67 / $93.33
United
Facility/Professional
Facility
Modifier
Typical Low / Median / Typical High
$23.44 / $23.44 / $54.95
United
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$23.44 / $125.89 / $134.90