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Integra Dermal Regeneration Template (DRT) or Omnigraft

Arizona 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 $69 · 10th–90th $30$2450%10%10th90th$69Professionalmedian $28 · 10th–90th $26$1260%50%10th90th$28$20.0$50.0$100.0$200.0$500.0

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
Facility
Modifier
Global
Typical Low
$46.77
Median
$46.77
Typical High
$50.12
Aetna
Setting
Professional
Modifier
Global
Typical Low
$26.92
Median
$26.92
Typical High
$30.90
BCBS
Setting
Facility
Modifier
Global
Typical Low
$53.70
Median
$97.72
Typical High
$331.13
BCBS
Setting
Professional
Modifier
Global
Typical Low
$97.72
Median
$138.04
Typical High
$234.42
Cigna
Setting
Facility
Modifier
Global
Typical Low
$131.83
Median
$208.93
Typical High
$239.88
Cigna
Setting
Professional
Modifier
Global
Typical Low
$125.89
Median
$125.89
Typical High
$125.89
Medica
Setting
Facility
Modifier
Global
Typical Low
$15.49
Median
$29.51
Typical High
$61.66
Medica
Setting
Professional
Modifier
Global
Typical Low
$26.30
Median
$26.30
Typical High
$56.23
United
Setting
Facility
Modifier
Global
Typical Low
$102.33
Median
$120.23
Typical High
$125.89
United
Setting
Professional
Modifier
Global
Typical Low
$125.89
Median
$125.89
Typical High
$125.89