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Integra Dermal Regeneration Template (DRT) or Omnigraft

Connecticut 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 $145 · 10th–90th $28$2450%20%10th90th$145Professionalmedian $27 · 10th–90th $27$1100%20%40%90th$27$50.0$100.0$200.0

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
$28.18
Median
$28.18
Typical High
$44.67
Aetna
Setting
Professional
Modifier
Global
Typical Low
$26.92
Median
$26.92
Typical High
$29.51
Anthem BCBS
Setting
Professional
Modifier
Global
Typical Low
$64.57
Median
$69.18
Typical High
$93.33
Cigna
Setting
Facility
Modifier
Global
Typical Low
$141.25
Median
$144.54
Typical High
$245.47
Cigna
Setting
Professional
Modifier
Global
Typical Low
$125.89
Median
$125.89
Typical High
$125.89
ConnectiCare
Setting
Professional
Modifier
Global
Typical Low
$28.18
Median
$28.18
Typical High
$67.61
United
Setting
Facility
Modifier
Global
Typical Low
$83.18
Median
$83.18
Typical High
$83.18
United
Setting
Professional
Modifier
Global
Typical Low
$25.12
Median
$50.12
Typical High
$125.89