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Integra Dermal Regeneration Template (DRT) or Omnigraft

Kentucky 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 $27 · 10th–90th $27$1740%50%90th$27Professionalmedian $27 · 10th–90th $27$680%50%90th$27$10.0$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
Professional
Modifier
Global
Typical Low
$26.92
Median
$26.92
Typical High
$38.90
CareSource
Setting
Facility
Modifier
Global
Typical Low
$26.92
Median
$26.92
Typical High
$42.66
CareSource
Setting
Professional
Modifier
Global
Typical Low
$26.92
Median
$28.84
Typical High
$38.02
Cigna
Setting
Facility
Modifier
Global
Typical Low
$151.36
Median
$173.78
Typical High
$173.78
Cigna
Setting
Professional
Modifier
Global
Typical Low
$35.48
Median
$125.89
Typical High
$616.60
Molina
Setting
Professional
Modifier
Global
Typical Low
$28.18
Median
$28.18
Typical High
$38.02
United
Setting
Facility
Modifier
Global
Typical Low
$102.33
Median
$102.33
Typical High
$120.23
United
Setting
Professional
Modifier
Global
Typical Low
$83.18
Median
$125.89
Typical High
$125.89