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Integra Dermal Regeneration Template (DRT) or Omnigraft

New Hampshire 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 $32 · 10th–90th $27$2950%20%10th90th$32Professionalmedian $27 · 10th–90th $27$1000%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
$131.83
Aetna
Setting
Professional
Modifier
Global
Typical Low
$26.92
Median
$26.92
Typical High
$32.36
Anthem BCBS
Setting
Professional
Modifier
Global
Typical Low
$69.18
Median
$69.18
Typical High
$79.43
Cigna
Setting
Facility
Modifier
Global
Typical Low
$144.54
Median
$251.19
Typical High
$338.84
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
$51.29
United
Setting
Facility
Modifier
Global
Typical Low
$208.93
Median
$208.93
Typical High
$208.93
United
Setting
Professional
Modifier
Global
Typical Low
$26.92
Median
$34.67
Typical High
$125.89
Well Sense
Setting
Facility
Modifier
Global
Typical Low
$81.28
Median
$81.28
Typical High
$112.20