go back

Integra Dermal Regeneration Template (DRT) or Omnigraft

New York 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 $27 · 10th–90th $27$1740%50%90th$27Professionalmedian $28 · 10th–90th $25$910%20%40%10th90th$28$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
$26.92
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
$67.61
Typical High
$67.61
CDPHP
Setting
Facility
Modifier
Global
Typical Low
$57.54
Median
$57.54
Typical High
$63.10
CDPHP
Setting
Professional
Modifier
Global
Typical Low
$57.54
Median
$57.54
Typical High
$57.54
Cigna
Setting
Facility
Modifier
Global
Typical Low
$32.36
Median
$165.96
Typical High
$186.21
Cigna
Setting
Professional
Modifier
Global
Typical Low
$125.89
Median
$125.89
Typical High
$125.89
Emblem Health
Setting
Facility
Modifier
Global
Typical Low
$67.61
Median
$144.54
Typical High
$338.84
Emblem Health
Setting
Professional
Modifier
Global
Typical Low
$67.61
Median
$67.61
Typical High
$162.18
Excellus BCBS
Setting
Facility
Modifier
Global
Typical Low
$26.92
Median
$26.92
Typical High
$28.18
Excellus BCBS
Setting
Professional
Modifier
Global
Typical Low
$26.92
Median
$28.18
Typical High
$28.18
MVP Health Care
Setting
Facility
Modifier
Global
Typical Low
$33.11
Median
$50,118.72
Typical High
$75,857.76
MVP Health Care
Setting
Professional
Modifier
Global
Typical Low
$28.18
Median
$28.18
Typical High
$43.65
United
Setting
Facility
Modifier
Global
Typical Low
$125.89
Median
$138.04
Typical High
$208.93
United
Setting
Professional
Modifier
Global
Typical Low
$23.99
Median
$26.30
Typical High
$125.89
Univera
Setting
Facility
Modifier
Global
Typical Low
$26.92
Median
$26.92
Typical High
$29.51
Univera
Setting
Professional
Modifier
Global
Typical Low
$26.92
Median
$28.18
Typical High
$28.18