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Integra Dermal Regeneration Template (DRT) or Omnigraft

Pennsylvania 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$4470%20%40%90th$27Professionalmedian $27 · 10th–90th $27$1260%50%90th$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
$45.71
Aetna
Setting
Professional
Modifier
Global
Typical Low
$26.92
Median
$26.92
Typical High
$28.18
Capital Blue Cross
Setting
Facility
Modifier
Global
Typical Low
$57.54
Median
$67.61
Typical High
$8,511.38
Capital Blue Cross
Setting
Professional
Modifier
Global
Typical Low
$66.07
Median
$66.07
Typical High
$66.07
Cigna
Setting
Facility
Modifier
Global
Typical Low
$125.89
Median
$446.68
Typical High
$478.63
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
$147.91
Geisinger
Setting
Professional
Modifier
Global
Typical Low
$11.75
Median
$128.82
Typical High
$199.53
Martin's Point
Setting
Facility
Modifier
Global
Typical Low
$26.92
Median
$26.92
Typical High
$45.71
Martin's Point
Setting
Professional
Modifier
Global
Typical Low
$26.92
Median
$26.92
Typical High
$28.18
UPMC Health Plan
Setting
Facility
Modifier
Global
Typical Low
$12.59
Median
$24.55
Typical High
$61.66
UPMC Health Plan
Setting
Professional
Modifier
Global
Typical Low
$21.38
Median
$21.38
Typical High
$24.55
United
Setting
Facility
Modifier
Global
Typical Low
$154.88
Median
$154.88
Typical High
$154.88
United
Setting
Professional
Modifier
Global
Typical Low
$25.12
Median
$125.89
Typical High
$134.90