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Integra Dermal Regeneration Template (DRT) or Omnigraft

Oklahoma 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 $29 · 10th–90th $28$1350%50%10th90th$29Professionalmedian $27 · 10th–90th $26$1260%50%10th90th$27$10.0$20.0$50.0$100.0$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
$28.84
Median
$28.84
Typical High
$28.84
Aetna
Setting
Professional
Modifier
Global
Typical Low
$26.92
Median
$26.92
Typical High
$38.02
Cigna
Setting
Facility
Modifier
Global
Typical Low
$144.54
Median
$331.13
Typical High
$363.08
Cigna
Setting
Professional
Modifier
Global
Typical Low
$125.89
Median
$125.89
Typical High
$125.89
Medica
Setting
Facility
Modifier
Global
Typical Low
$26.30
Median
$32.36
Typical High
$89.13
Medica
Setting
Professional
Modifier
Global
Typical Low
$23.44
Median
$26.30
Typical High
$57.54
United
Setting
Facility
Modifier
Global
Typical Low
$102.33
Median
$102.33
Typical High
$208.93
United
Setting
Professional
Modifier
Global
Typical Low
$125.89
Median
$125.89
Typical High
$125.89