go back

Integra Dermal Regeneration Template (DRT) or Omnigraft

Alaska 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)

Rates data updated July 2026.

Facilitymedian $40 · 10th–90th $18$1780%10%10th90th$40Professionalmedian $100 · 10th–90th $27$4070%20%10th90th$100$10.0$50.0$200.0$1.0K

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
Setting
Professional
Modifier
Global
Typical Low
$26.92
Median
$26.92
Typical High
$50.12
Cigna
Setting
Facility
Modifier
Global
Typical Low
$144.54
Median
$144.54
Typical High
$144.54
Cigna
Setting
Professional
Modifier
Global
Typical Low
$125.89
Median
$125.89
Typical High
$125.89
Moda Health
Setting
Facility
Modifier
Global
Typical Low
$16.22
Median
$32.36
Typical High
$89.13
Moda Health
Setting
Professional
Modifier
Global
Typical Low
$141.25
Median
$302.00
Typical High
$489.78
Premera BCBS
Setting
Facility
Modifier
Global
Typical Low
$39.81
Median
$114.82
Typical High
$177.83
Premera BCBS
Setting
Professional
Modifier
Global
Typical Low
$81.28
Median
$89.13
Typical High
$97.72
Providence
Setting
Facility
Modifier
Global
Typical Low
$18.20
Median
$42.66
Typical High
$302.00
Providence
Setting
Professional
Modifier
Global
Typical Low
$37.15
Median
$60.26
Typical High
$125.89
United
Setting
Professional
Modifier
Global
Typical Low
$30.20
Median
$190.55
Typical High
$380.19