Integra or Omnigraft dermal regeneration template 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

KIT OMNIGRAFT 2.5X2.5CM DERMAL REGENERATION MATRIX - Q4105-COST PER SQ CM

Troy, NY

See all hospitals reporting HCPCS Q4105 →

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Pricing by billing methodology

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How this price compares nationally

Samaritan Hospital’s median price of $156 is 24% above the median hospital's median price ($127), higher than 69% of the 1,343 hospitals reporting HCPCS Q4105. The highlighted bar is where this hospital falls; shaded is the middle 50% of hospitals.

Payers reporting HCPCS Q4105 at Samaritan Hospital

Negotiated rates from the hospital’s own file: 12 payers, 17 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	Aetna aetna medicare advantage facility · percent of total billed charges · bothfrom % of charges	$53	$53	$14	26%	—	$39 – $67
2	UnitedHealthcare uhc essential plan medicaid facility · percent of total billed charges · bothfrom % of charges	$85	$85	$22	26%	—	$63 – $107
3	UnitedHealthcare united healthcare medicaid harp chip facility · percent of total billed charges · bothfrom % of charges	$85	$85	$22	26%	—	$63 – $107
4	Excellus blue shield of ne new york medicare adv facility · percent of total billed charges · bothfrom % of charges	$106	$106	$28	26%	—	$78 – $134
5	Highmark blue shield of ne new york medicare adv facility · percent of total billed charges · bothfrom % of charges	$106	$106	$28	26%	—	$78 – $134
6	Anthem empire bcbs blue access facility · percent of total billed charges · bothfrom % of charges	$159	$159	$42	26%	—	$117 – $200
7	Anthem empire bcbs hmo epo ppo indemnity facility · percent of total billed charges · bothfrom % of charges	$159	$159	$42	26%	—	$117 – $200
8	Blue Cross Blue Shield empire bcbs hmo epo ppo indemnity facility · percent of total billed charges · bothfrom % of charges	$159	$159	$42	26%	—	$117 – $200
9	UnitedHealthcare empire bcbs hmo epo ppo indemnity facility · percent of total billed charges · bothfrom % of charges	$159	$159	$42	26%	—	$117 – $200
10	WellCare wellcare ep 1&2 medicaid facility · percent of total billed charges · bothfrom % of charges	$159	$159	$42	26%	—	$117 – $200
11	Wellmark empire bcbs hmo epo ppo indemnity facility · percent of total billed charges · bothfrom % of charges	$159	$159	$42	26%	—	$117 – $200
12	First Health first health facility · percent of total billed charges · bothfrom % of charges	$169	$169	$44	26%	—	$125 – $214
13	Cigna cigna facility · percent of total billed charges · bothfrom % of charges	$180	$180	$47	26%	—	$133 – $227
14	MultiPlan beech street facility · percent of total billed charges · bothfrom % of charges	$191	$191	$50	26%	—	$141 – $240
15	MultiPlan multiplan facility · percent of total billed charges · bothfrom % of charges	$191	$191	$50	26%	—	$141 – $240
16	Phcs multiplan facility · percent of total billed charges · bothfrom % of charges	$191	$191	$50	26%	—	$141 – $240
17	UnitedHealthcare united healthcare facility · percent of total billed charges · bothfrom % of charges	$212	$212	$55	26%	—	$156 – $267

Last updated: Mar 31, 2026

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