go back

Integra Dermal Regeneration Template (DRT) or Omnigraft

Maine 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 $145 · 10th–90th $145$3630%50%90th$145Professionalmedian $27 · 10th–90th $27$1070%50%90th$27$10.0$20.0$50.0$100.0$200.0

Distribution of negotiated rates across all payers (price axis is log-scale). Facility and professional rates are different services and are charted separately. Small sample; interpret with caution. Need provider-level prices? Contact us.

Insurance Carrier
Aetna
Setting
Professional
Modifier
Global
Typical Low
$26.92
Median
$26.92
Typical High
$28.18
Anthem BCBS
Setting
Professional
Modifier
Global
Typical Low
$67.61
Median
$69.18
Typical High
$69.18
Cigna
Setting
Facility
Modifier
Global
Typical Low
$144.54
Median
$144.54
Typical High
$363.08
Cigna
Setting
Professional
Modifier
Global
Typical Low
$125.89
Median
$125.89
Typical High
$125.89
Harvard Pilgrim
Setting
Professional
Modifier
Global
Typical Low
$26.92
Median
$26.92
Typical High
$32.36
Martin's Point
Setting
Professional
Modifier
Global
Typical Low
$26.92
Median
$26.92
Typical High
$120.23
United
Setting
Professional
Modifier
Global
Typical Low
$26.92
Median
$30.20
Typical High
$125.89