Hospitals report these codes with terse, inconsistent chargemaster text. This plain-English title was written by an AI model from that text and has not been reviewed by a person, so it can be wrong. The prices on this page come straight from hospital filings and do not depend on it.
Original text from hospital filings
DRSG BIOLOGICAL 5X4IN INTEGRA BOVINE CLLGN GLYCOSAMINOGLYCAN
Monroe, GA
See all hospitals reporting HCPCS Q4104 →Price type
Piedmont Walton’s median price of $137 is about the same as the median hospital's median price ($136), higher than 51% of the 1,714 hospitals reporting HCPCS Q4104. The highlighted bar is where this hospital falls; shaded is the middle 50% of hospitals.
Negotiated rates from the hospital’s own file: 9 payers, 12 plan rates. A facility fee, a professional fee, a per diem and a case rate are different bills, so each is listed on its own. Open a payer to see it across hospitals.
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| # | |||||||
|---|---|---|---|---|---|---|---|
| 1 | Cigna cigna fee schedule · both | $105 | $105 | $33 | 31% | — | $72 – $137 |
| 2 | Cigna cigna connect fee schedule · both | $105 | $105 | $33 | 31% | — | $72 – $137 |
| 3 | UnitedHealthcare united healthcare fee schedule · both | $160 | $160 | $88 | 55% | — | $72 – $248 |
| 4 | UnitedHealthcare united healthcare exchange fee schedule · both | $160 | $160 | $88 | 55% | — | $72 – $248 |
| 5 | Blue Cross Blue Shield blue cross hmo percent of total billed charges · bothfrom % of charges | $9.1k | $9.1k | $9.1k | 100% | — | $32 – $18.3k |
| 6 | Blue Cross Blue Shield blue cross ppo percent of total billed charges · bothfrom % of charges | $9.6k | $9.6k | $9.6k | 100% | — | $34 – $19.2k |
| 7 | First Health first health percent of total billed charges · bothfrom % of charges | $14.5k | $14.5k | $14.4k | 100% | — | $50 – $28.9k |
| 8 | MultiPlan multiplan percent of total billed charges · bothfrom % of charges | $16.5k | $16.5k | $16.5k | 100% | — | $58 – $33.0k |
| 9 | Phcs phcs percent of total billed charges · bothfrom % of charges | $16.5k | $16.5k | $16.5k | 100% | — | $58 – $33.0k |
| 10 | Kaiser kaiser percent of total billed charges · bothfrom % of charges | $17.6k | $17.6k | $17.5k | 100% | — | $61 – $35.1k |
| 11 | Beechstreet beechstreet percent of total billed charges · bothfrom % of charges | $18.6k | $18.6k | $18.5k | 100% | — | $65 – $37.1k |
| 12 | Aetna aetna hmo/ppo percent of total billed charges · bothfrom % of charges | $28.0k | $28.0k | — | — | — | $28.0k – $28.0k |
Last updated: Jul 1, 2026
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