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Integra Dermal Regeneration Template (DRT) or Omnigraft

Ohio 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.

How much does Integra Dermal Regeneration Template (DRT) or Omnigraft cost?

$28.18

Typical negotiated rate. In Ohio, July 2026.

Insurers have agreed to pay about $28.18 for this service. The price depends on where it is billed: about $28.18 from a physician practice, and about $102 from a hospital or other facility. The two figures are alternatives, not parts of one bill.

These are rates insurers have negotiated with providers, not the amount a patient is billed. What you owe depends on your plan's deductible and coinsurance. Based on rates published by 8 insurance carriers under federal price transparency rules.

Where it's billed changes the price

Billed byTypicalRange
Physician practiceA doctor's office, clinic or independent provider$28.18$26.92 to $64.57
FacilityA hospital or hospital-owned outpatient department$102$26.92 to $251

How much rates vary

Facilitymedian $102 · 10th to 90th $27 to $316Professionalmedian $28 · 10th to 90th $27 to $126
$50$100$200facility $102professional $28

Distribution of negotiated rates across all payers (price axis is log-scale). Each curve is scaled to its own total: facility and professional rates are different services, shown together to compare where they cluster. Need provider-level prices or 24+ months of history? Contact us.

Rates by insurance carrier

Insurance Carrier
Aetna
Setting
Facility
Modifier
Global
Typical Low
$26.92
Median
$26.92
Typical High
$31.62
Aetna
Setting
Professional
Modifier
Global
Typical Low
$26.92
Median
$26.92
Typical High
$29.51
Anthem BCBS
Setting
Professional
Modifier
Global
Typical Low
$26.92
Median
$34.67
Typical High
$138.04
CareSource
Setting
Facility
Modifier
Global
Typical Low
$26.92
Median
$26.92
Typical High
$26.92
CareSource
Setting
Professional
Modifier
Global
Typical Low
$26.92
Median
$26.92
Typical High
$36.31
Cigna
Setting
Facility
Modifier
Global
Typical Low
$239.88
Median
$269.15
Typical High
$416.87
Cigna
Setting
Professional
Modifier
Global
Typical Low
$125.89
Median
$125.89
Typical High
$125.89
Medical Mutual of Ohio
Setting
Facility
Modifier
Global
Typical Low
$181.97
Median
$269.15
Typical High
$389.05
Medical Mutual of Ohio
Setting
Professional
Modifier
Global
Typical Low
$81.28
Median
$125.89
Typical High
$125.89
Molina
Setting
Professional
Modifier
Global
Typical Low
$29.51
Median
$87.10
Typical High
$128.82
SummaCare
Setting
Facility
Modifier
Global
Typical Low
$125.89
Median
$141.25
Typical High
$158.49
SummaCare
Setting
Professional
Modifier
Global
Typical Low
$54.95
Median
$81.28
Typical High
$165.96
United
Setting
Facility
Modifier
Global
Typical Low
$102.33
Median
$102.33
Typical High
$275.42
United
Setting
Professional
Modifier
Global
Typical Low
$102.33
Median
$125.89
Typical High
$125.89

Where Ohio sits

The same service costs 3.3 times more in Minnesota than in West Virginia. Every bar is a state, most expensive first. Touch or drag across it to read any state, then open that state for its carriers and full range.

Ohio· 17th of 51

$28.18

MN $89.13WV $26.92

Median negotiated rate in each state, from every insurer that publishes one. States where no insurer publishes a rate for this service are not shown.