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Integra Dermal Regeneration Template (DRT) or Omnigraft

Florida 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 $126 · 10th–90th $27$154,8820%20%10th90th$126Professionalmedian $27 · 10th–90th $27$1260%50%90th$27$2.0$20.0$200.0$2.0K$20.0K$200.0K

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
Facility
Modifier
Global
Typical Low
$26.92
Median
$26.92
Typical High
$26.92
Aetna
Setting
Professional
Modifier
Global
Typical Low
$26.92
Median
$26.92
Typical High
$29.51
AvMed
Setting
Facility
Modifier
Global
Typical Low
$69.18
Median
$107.15
Typical High
$125.89
AvMed
Setting
Professional
Modifier
Global
Typical Low
$26.92
Median
$85.11
Typical High
$131.83
Cigna
Setting
Facility
Modifier
Global
Typical Low
$144.54
Median
$190.55
Typical High
$257.04
Cigna
Setting
Professional
Modifier
Global
Typical Low
$125.89
Median
$125.89
Typical High
$125.89
Florida Blue
Setting
Facility
Modifier
Global
Typical Low
$158.49
Median
$102,329.30
Typical High
$208,929.61
Florida Blue
Setting
Professional
Modifier
Global
Typical Low
$11.48
Median
$85.11
Typical High
$131.83
Molina
Setting
Professional
Modifier
Global
Typical Low
$32.36
Median
$33.11
Typical High
$41.69
United
Setting
Facility
Modifier
Global
Typical Low
$25.70
Median
$125.89
Typical High
$154.88
United
Setting
Professional
Modifier
Global
Typical Low
$36.31
Median
$125.89
Typical High
$125.89
Wellpoint
Setting
Professional
Modifier
Global
Typical Low
$30.20
Median
$30.20
Typical High
$128.82