HCPCS Q4105

Integra dermal regeneration template (drt) or integra omnigraft dermal regeneration matrix, per square centimeter (add-on, list separately in addition to primary procedure)

Current codeSkin Substitute Products38 hospitals with prices

Description from CMS's HCPCS Level II code file.

What Washington hospitals publish for this code

Medicaid managed care: Rate for an Apple Health managed-care plan. Applies only to members of that plan.

Prices for HCPCS Q4105 by hospital
Hospital	Medicaid managed care rates (lowest – highest)	Cash price	List price (before discounts)
Cascade Valley HospitalArlington	$6001 plan	$480	$600
Harborview Medical CenterSeattleFile dated 2026-04-01	—	$37.84 – $33,671	$54.05 – $48,102
Highline Medical CenterBurienFile dated 2026-02-28	—	$6,611 – $11,358	$21,650 – $37,197
Island HospitalAnacortes	$1491 plan	$1,458 – $2,013	$1,458 – $2,013
Kadlec Regional Medical CenterRichlandFile dated 2026-04-01	—	$2,039 – $4,279	$2,913 – $6,113
Legacy Salmon Creek Medical CenterVancouverFile dated 2026-04-01	—	$345	$531
Prov Sacred HRT Med Ctr & Childs Hosp.SpokaneFile dated 2026-04-01	—	$2,079 – $5,762	$2,970 – $8,231
Providence Centralia HospitalCentraliaFile dated 2026-04-01	—	$3,395 – $9,332	$6,528 – $17,947
Providence Holy Family HospitalSpokaneFile dated 2026-04-01	—	$2,079 – $5,762	$2,970 – $8,231
Providence Mount Carmel HospitalColvilleFile dated 2026-04-01	—	$1,983 – $5,504	$2,833 – $7,863
Providence Regional Medical Center EverettEverettFile dated 2026-04-01	—	$3,547 – $7,838	$6,821 – $15,073
Providence St Joseph HospitalChewelahFile dated 2026-04-01	—	$1,983 – $5,504	$2,833 – $7,863
Providence St Mary Medical CenterWalla WallaFile dated 2026-04-01	—	$2,046 – $4,919	$2,922 – $7,027
Providence St Peter HospitalOlympiaFile dated 2026-04-01	—	$3,395 – $9,332	$6,528 – $17,947
Skagit Valley HospitalMount Vernon	—	$480	$600
St Anthony HospitalGig HarborFile dated 2026-02-28	—	$6,585 – $11,314	$21,650 – $37,197
St Clare HospitalLakewoodFile dated 2026-02-28	—	$6,241 – $10,722	$21,650 – $37,197
St Elizabeth HospitalEnumclawFile dated 2026-02-28	$6,062 – $12,3385 plans	$7,651 – $13,144	$21,650 – $37,197
St Francis Community HospitalFederal WayFile dated 2026-02-28	—	$6,794 – $11,673	$21,650 – $37,197
St Joseph Medical CenterTacomaFile dated 2026-02-28	—	$7,171 – $12,320	$21,650 – $37,197
St Michael Medical CenterSilverdaleFile dated 2026-02-28	—	$9,555 – $16,417	$21,650 – $37,197
Swedish Edmonds HospitalEdmondsFile dated 2026-04-01	—	$2,153 – $5,492	$4,485 – $11,442
Swedish IssaquahIssaquahFile dated 2026-04-01	—	$2,153 – $5,492	$4,485 – $11,442
Swedish Medical CenterSeattleFile dated 2026-04-01	—	$2,153 – $5,492	$4,485 – $11,442
Swedish Medical Center / Cherry HillSeattleFile dated 2026-04-01	—	$2,153 – $5,492	$4,485 – $11,442
University of Washington Medical CtrSeattleFile dated 2026-04-01	—	$3,180 – $30,171	$4,543 – $43,101

Lowest and highest amounts each hospital lists for this code during a hospital stay, including lines it lists for both settings or without saying which. A doctor’s fee is shown separately when the hospital lists one with the code. “At least” means plans were counted in more than one group and some may be the same plan. This is one line of a bill; most care brings several.

Medicare (traditional) reference

Only for people on original Medicare. These are CMS’s 2026 amounts. They aren’t what private insurance or cash patients pay.

Doctor's fee, Seattle (King County): $156 in an office; $156 in a hospital or surgery center
Doctor's fee, rest of Washington: $134 in an office; $134 in a hospital or surgery center
Hospital outpatient payment (national): $127 (APC 6000)
Surgery center payment (national): $127