go back

Integra Dermal Regeneration Template (DRT) or Omnigraft

New Jersey 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 $209 · 10th–90th $27$18,1970%5%10%10th90th$209Professionalmedian $27 · 10th–90th $23$1260%50%10th90th$27$10.0$50.0$200.0$1.0K$5.0K$20.0K

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
$97.72
Aetna
Setting
Professional
Modifier
Global
Typical Low
$26.92
Median
$26.92
Typical High
$29.51
Cigna
Setting
Facility
Modifier
Global
Typical Low
$30.90
Median
$40.74
Typical High
$144.54
Cigna
Setting
Professional
Modifier
Global
Typical Low
$125.89
Median
$125.89
Typical High
$125.89
Emblem Health
Setting
Professional
Modifier
Global
Typical Low
$67.61
Median
$67.61
Typical High
$162.18
Horizon BCBS
Setting
Facility
Modifier
Global
Typical Low
$69.18
Median
$9,332.54
Typical High
$20,417.38
Horizon BCBS
Setting
Professional
Modifier
Global
Typical Low
$23.44
Median
$23.44
Typical High
$23.44
United
Setting
Facility
Modifier
Global
Typical Low
$125.89
Median
$154.88
Typical High
$316.23
United
Setting
Professional
Modifier
Global
Typical Low
$24.55
Median
$52.48
Typical High
$125.89