go back

Integra Dermal Regeneration Template (DRT) or Omnigraft

Missouri 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 $72 · 10th–90th $27$1580%20%10th90th$72Professionalmedian $46 · 10th–90th $27$1320%20%10th90th$46$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
$27.54
Typical High
$87.10
Aetna
Setting
Professional
Modifier
Global
Typical Low
$26.92
Median
$26.92
Typical High
$81.28
Anthem BCBS
Setting
Professional
Modifier
Global
Typical Low
$26.92
Median
$97.72
Typical High
$131.83
BCBS
Setting
Professional
Modifier
Global
Typical Low
$123.03
Median
$144.54
Typical High
$194.98
Cigna
Setting
Facility
Modifier
Global
Typical Low
$144.54
Median
$239.88
Typical High
$371.54
Cigna
Setting
Professional
Modifier
Global
Typical Low
$125.89
Median
$125.89
Typical High
$125.89
Medica
Setting
Facility
Modifier
Global
Typical Low
$26.30
Median
$36.31
Typical High
$81.28
Medica
Setting
Professional
Modifier
Global
Typical Low
$23.44
Median
$26.30
Typical High
$134.90
United
Setting
Facility
Modifier
Global
Typical Low
$102.33
Median
$125.89
Typical High
$173.78
United
Setting
Professional
Modifier
Global
Typical Low
$51.29
Median
$125.89
Typical High
$125.89