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Integra Dermal Regeneration Template (DRT) or Omnigraft

Idaho 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 $34 · 10th–90th $14$1410%10%10th90th$34Professionalmedian $34 · 10th–90th $27$2190%20%10th90th$34$10.0$20.0$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
$117.49
Median
$117.49
Typical High
$117.49
Aetna
Setting
Professional
Modifier
Global
Typical Low
$26.92
Median
$26.92
Typical High
$50.12
BCBS
Setting
Facility
Modifier
Global
Typical Low
$11.22
Median
$20.89
Typical High
$61.66
BCBS
Setting
Professional
Modifier
Global
Typical Low
$67.61
Median
$67.61
Typical High
$67.61
Cigna
Setting
Facility
Modifier
Global
Typical Low
$141.25
Median
$144.54
Typical High
$323.59
Cigna
Setting
Professional
Modifier
Global
Typical Low
$125.89
Median
$125.89
Typical High
$125.89
Moda Health
Setting
Facility
Modifier
Global
Typical Low
$13.80
Median
$30.90
Typical High
$89.13
Moda Health
Setting
Professional
Modifier
Global
Typical Low
$141.25
Median
$218.78
Typical High
$251.19
Molina
Setting
Professional
Modifier
Global
Typical Low
$30.20
Median
$30.20
Typical High
$77.62
Regence BlueShield
Setting
Professional
Modifier
Global
Typical Low
$125.89
Median
$151.36
Typical High
$151.36
Select Health
Setting
Facility
Modifier
Global
Typical Low
$21.88
Median
$117.49
Typical High
$302.00
Select Health
Setting
Professional
Modifier
Global
Typical Low
$123.03
Median
$147.91
Typical High
$234.42
United
Setting
Professional
Modifier
Global
Typical Low
$125.89
Median
$125.89
Typical High
$125.89