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Integra Dermal Regeneration Template (DRT) or Omnigraft

Illinois 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 $182 · 10th–90th $27$2630%10%10th90th$182Professionalmedian $27 · 10th–90th $27$1260%50%90th$27$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
$26.92
Median
$26.92
Typical High
$117.49
Aetna
Setting
Professional
Modifier
Global
Typical Low
$26.92
Median
$26.92
Typical High
$29.51
BCBS
Setting
Facility
Modifier
Global
Typical Low
$39.81
Median
$204.17
Typical High
$281.84
BCBS
Setting
Professional
Modifier
Global
Typical Low
$26.30
Median
$128.82
Typical High
$128.82
Cigna
Setting
Facility
Modifier
Global
Typical Low
$169.82
Median
$194.98
Typical High
$302.00
Cigna
Setting
Professional
Modifier
Global
Typical Low
$81.28
Median
$125.89
Typical High
$125.89
Hally Health
Setting
Professional
Modifier
Global
Typical Low
$23.99
Median
$69.18
Typical High
$288.40
Hally Health
Setting
Facility
Modifier
Global
Typical Low
$100.00
Median
$100.00
Typical High
$100.00
Hally Health
Setting
Professional
Modifier
Global
Typical Low
$34.67
Median
$34.67
Typical High
$34.67
Molina
Setting
Professional
Modifier
Global
Typical Low
$30.20
Median
$30.20
Typical High
$30.20
United
Setting
Facility
Modifier
Global
Typical Low
$102.33
Median
$102.33
Typical High
$208.93
United
Setting
Professional
Modifier
Global
Typical Low
$27.54
Median
$125.89
Typical High
$125.89