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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 July 2026.

Facilitymedian $224 · 10th–90th $27$5130%10%10th90th$224Professionalmedian $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
$26.92
Aetna
Setting
Professional
Modifier
Global
Typical Low
$26.92
Median
$26.92
Typical High
$28.18
Anthem BCBS
Setting
Facility
Modifier
Global
Typical Low
$33.88
Median
$263.03
Typical High
$512.86
Anthem BCBS
Setting
Professional
Modifier
Global
Typical Low
$26.92
Median
$26.92
Typical High
$67.61
CareSource
Setting
Facility
Modifier
Global
Typical Low
$26.92
Median
$32.36
Typical High
$48.98
Cigna
Setting
Facility
Modifier
Global
Typical Low
$26.30
Median
$346.74
Typical High
$346.74
Cigna
Setting
Professional
Modifier
Global
Typical Low
$81.28
Median
$125.89
Typical High
$125.89
United
Setting
Facility
Modifier
Global
Typical Low
$102.33
Median
$257.04
Typical High
$257.04
United
Setting
Professional
Modifier
Global
Typical Low
$125.89
Median
$125.89
Typical High
$125.89