Integra bone matrix wound dressing at Samaritan Hospital

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.

Model: claude-haiku-5-5
Provider: anthropic
API: message_batches
Reasoning effort: low
Max output tokens: 4096
Prompt version (hash): 444523875572
Generated: October 20, 2026

Original text from hospital filings

DRSG WOUND MATRIX 8X10IN 500SQCM-Q4104-COST PER SQ CM

Troy, NY

See all hospitals reporting HCPCS Q4104 →

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Price type

How this price compares nationally

Samaritan Hospital’s median price of $84 is 38% below the median hospital's median price ($136), higher than 22% of the 1,723 hospitals reporting HCPCS Q4104. The highlighted bar is where this hospital falls; shaded is the middle 50% of hospitals.

Payers reporting HCPCS Q4104 at Samaritan Hospital

Negotiated rates from the hospital’s own file: 15 payers, 33 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	Blue Cross Blue Shield blue shield of ne new york hmo facility · percent of total billed charges · bothfrom % of charges	$30	$30	—	—	—	$30 – $30
2	Blue Cross Blue Shield blue shield of ne new york ppo facility · percent of total billed charges · bothfrom % of charges	$30	$30	—	—	—	$30 – $30
3	Carefirst blue shield of ne new york hmo facility · percent of total billed charges · bothfrom % of charges	$30	$30	—	—	—	$30 – $30
4	Carefirst blue shield of ne new york ppo facility · percent of total billed charges · bothfrom % of charges	$30	$30	—	—	—	$30 – $30
5	Excellus blue shield of ne new york ppo facility · percent of total billed charges · bothfrom % of charges	$30	$30	—	—	—	$30 – $30
6	Highmark blue shield of ne new york ascend facility · percent of total billed charges · bothfrom % of charges	$30	$30	—	—	—	$30 – $30
7	Highmark blue shield of ne new york hmo facility · percent of total billed charges · bothfrom % of charges	$30	$30	—	—	—	$30 – $30
8	Highmark blue shield of ne new york ppo facility · percent of total billed charges · bothfrom % of charges	$30	$30	—	—	—	$30 – $30
9	Premera blue shield of ne new york ppo facility · percent of total billed charges · bothfrom % of charges	$30	$30	—	—	—	$30 – $30
10	Regence blue shield of ne new york ppo facility · percent of total billed charges · bothfrom % of charges	$30	$30	—	—	—	$30 – $30
11	Wellmark blue shield of ne new york hmo facility · percent of total billed charges · bothfrom % of charges	$30	$30	—	—	—	$30 – $30
12	Wellmark blue shield of ne new york ppo facility · percent of total billed charges · bothfrom % of charges	$30	$30	—	—	—	$30 – $30
13	Anthem empire medicaid facility · percent of total billed charges · bothfrom % of charges	$55	$55	—	—	—	$55 – $55
14	Anthem empire medicaid essential 1 2 3 4 facility · percent of total billed charges · bothfrom % of charges	$55	$55	—	—	—	$55 – $55
15	Excellus empire medicaid facility · percent of total billed charges · bothfrom % of charges	$55	$55	—	—	—	$55 – $55
16	Excellus empire medicaid essential 1 2 3 4 facility · percent of total billed charges · bothfrom % of charges	$55	$55	—	—	—	$55 – $55
17	Cigna cigna facility · percent of total billed charges · bothfrom % of charges	$86	$129	$81	63%	—	$47 – $273
18	Aetna aetna medicare advantage facility · percent of total billed charges · bothfrom % of charges	$44	$392	$927	237%	—	$17 – $2.8k
19	UnitedHealthcare uhc essential plan medicaid facility · percent of total billed charges · bothfrom % of charges	$45	$560	$1.4k	252%	—	$22 – $4.6k
20	UnitedHealthcare united healthcare medicaid harp chip facility · percent of total billed charges · bothfrom % of charges	$45	$560	$1.4k	252%	—	$22 – $4.6k
21	Excellus blue shield of ne new york medicare adv facility · percent of total billed charges · bothfrom % of charges	$88	$784	$1.9k	237%	—	$34 – $5.7k
22	Highmark blue shield of ne new york medicare adv facility · percent of total billed charges · bothfrom % of charges	$88	$784	$1.9k	237%	—	$34 – $5.7k
23	First Health first health facility · percent of total billed charges · bothfrom % of charges	$90	$1.1k	$2.8k	252%	—	$44 – $9.1k
24	Anthem empire bcbs blue access facility · percent of total billed charges · bothfrom % of charges	$132	$1.2k	$2.8k	237%	—	$51 – $8.5k
25	Anthem empire bcbs hmo epo ppo indemnity facility · percent of total billed charges · bothfrom % of charges	$132	$1.2k	$2.8k	237%	—	$51 – $8.5k

Page 1 of 2 · 33 rates

Last updated: Mar 31, 2026

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