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Integra Dermal Regeneration Template (DRT) or Omnigraft

Indiana 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 October 2026.

How much does Integra Dermal Regeneration Template (DRT) or Omnigraft cost?

$26.92

Typical negotiated rate. In Indiana, October 2026.

Insurers have agreed to pay about $26.92 for this service. The price depends on where it is billed: about $26.92 from a physician practice, and about $191 from a hospital or other facility.

These are rates insurers have negotiated with providers, not the amount a patient is billed. What you owe depends on your plan's deductible and coinsurance. Based on rates published by 6 insurance carriers under federal price transparency rules.

Prices by location type

Billed byTypicalRange
Physician practiceA doctor's office, clinic or independent provider$26.92$26.92 to $126
FacilityA hospital or hospital-owned outpatient department$191$135 to $275

How much rates vary

Facilitymedian $191 · 10th to 90th $110 to $417Professionalmedian $27 · 10th to 90th $27 to $126
$20$50$100$200$500$1K$2Kfacility $191professional $27

Distribution of negotiated rates across all payers (price axis is log-scale). Need provider-level prices or 24+ months of history? Contact us.

Rates by insurance carrier

Insurance Carrier
Aetna
Setting
Facility
Modifier
None
Typical Low
$26.92
Median
$26.92
Typical High
$26.92
Aetna
Setting
Professional
Modifier
None
Typical Low
$26.92
Median
$26.92
Typical High
$26.92
Anthem BCBS
Setting
Facility
Modifier
None
Typical Low
$125.89
Median
$181.97
Typical High
$501.19
Anthem BCBS
Setting
Professional
Modifier
None
Typical Low
$26.92
Median
$26.92
Typical High
$117.49
CareSource
Setting
Facility
Modifier
None
Typical Low
$26.92
Median
$40.74
Typical High
$53.70
Cigna
Setting
Facility
Modifier
None
Typical Low
$144.54
Median
$229.09
Typical High
$346.74
Cigna
Setting
Professional
Modifier
None
Typical Low
$125.89
Median
$125.89
Typical High
$616.60
Physicians Health Plan of Northern Indiana
Setting
Facility
Modifier
None
Typical Low
$53.70
Median
$234.42
Typical High
$2,137.96
Physicians Health Plan of Northern Indiana
Setting
Professional
Modifier
None
Typical Low
$37.15
Median
$61.66
Typical High
$190.55
United
Setting
Professional
Modifier
None
Typical Low
$125.89
Median
$125.89
Typical High
$173.78

Where Indiana sits

The same service costs 4.7 times more in Oregon than in Washington, DC. Every bar is a state, most expensive first. Touch or drag across it to read any state, then open that state for its carriers and full range.

Indiana· 48th of 51

$26.92

OR $126DC $26.92

Median negotiated rate in each state, from every insurer that publishes one. States where no insurer publishes a rate for this service are not shown.