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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.

Facilitymedian $102 · 10th–90th $27$3160%20%10th90th$102Professionalmedian $28 · 10th–90th $27$1260%20%40%10th90th$28$2.0$10.0$50.0$200.0

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
$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