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Integra Dermal Regeneration Template (DRT) or Omnigraft

Louisiana 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 $29 · 10th–90th $27$1260%50%10th90th$29Professionalmedian $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
$27.54
Aetna
Setting
Professional
Modifier
Global
Typical Low
$26.92
Median
$26.92
Typical High
$29.51
BCBS
Setting
Facility
Modifier
Global
Typical Low
$28.84
Median
$28.84
Typical High
$28.84
BCBS
Setting
Professional
Modifier
Global
Typical Low
$28.84
Median
$28.84
Typical High
$28.84
Christus
Setting
Facility
Modifier
Global
Typical Low
$39.81
Median
$39.81
Typical High
$120.23
Cigna
Setting
Facility
Modifier
Global
Typical Low
$125.89
Median
$239.88
Typical High
$346.74
Cigna
Setting
Professional
Modifier
Global
Typical Low
$125.89
Median
$125.89
Typical High
$125.89
United
Setting
Facility
Modifier
Global
Typical Low
$102.33
Median
$125.89
Typical High
$154.88
United
Setting
Professional
Modifier
Global
Typical Low
$107.15
Median
$125.89
Typical High
$128.82