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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 October 2026.

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

$67.61

Typical negotiated rate. In Pennsylvania, October 2026.

Insurers have agreed to pay about $67.61 for this service. The price depends on where it is billed: about $67.61 from a physician practice, and about $166 from a hospital or other facility.

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 9 insurance carriers under federal price transparency rules.

Prices by location type

Billed byTypicalRange
Physician practiceA doctor's office, clinic or independent provider$67.61$26.92 to $126
FacilityA hospital or hospital-owned outpatient department$166$77.62 to $214

How much rates vary

Facilitymedian $166 · 10th to 90th $27 to $479Professionalmedian $68 · 10th to 90th $27 to $126
$100$1K$10Kfacility $166professional $68

Distribution of negotiated rates across all payers (price axis is log-scale). Need provider-level prices or 24+ months of history? Contact us.

Rates by insurance carrier

Insurance Carrier
Aetna
Setting
Facility
Modifier
None
Typical Low
$26.92
Median
$26.92
Typical High
$26.92
Aetna
Setting
Professional
Modifier
None
Typical Low
$26.92
Median
$26.92
Typical High
$26.92
Capital Blue Cross
Setting
Facility
Modifier
None
Typical Low
$60.26
Median
$67.61
Typical High
$5,011.87
Capital Blue Cross
Setting
Professional
Modifier
None
Typical Low
$61.66
Median
$67.61
Typical High
$67.61
Cigna
Setting
Facility
Modifier
None
Typical Low
$125.89
Median
$181.97
Typical High
$478.63
Cigna
Setting
Professional
Modifier
None
Typical Low
$125.89
Median
$125.89
Typical High
$131.83
Emblem Health
Setting
Professional
Modifier
None
Typical Low
$67.61
Median
$67.61
Typical High
$234.42
Geisinger
Setting
Professional
Modifier
None
Typical Low
$11.75
Median
$117.49
Typical High
$199.53
Martin's Point
Setting
Facility
Modifier
None
Typical Low
$26.92
Median
$26.92
Typical High
$26.92
Martin's Point
Setting
Professional
Modifier
None
Typical Low
$26.92
Median
$26.92
Typical High
$26.92
Oscar Health
Setting
Professional
Modifier
None
Typical Low
$27.54
Median
$27.54
Typical High
$53.70
UPMC Health Plan
Setting
Facility
Modifier
None
Typical Low
$21.38
Median
$24.55
Typical High
$32.36
UPMC Health Plan
Setting
Professional
Modifier
None
Typical Low
$21.38
Median
$24.55
Typical High
$24.55
United
Setting
Professional
Modifier
None
Typical Low
$114.82
Median
$125.89
Typical High
$134.90

Where Pennsylvania sits

The same service costs 4.7 times more in Oregon than in Washington, DC. 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.

Pennsylvania· 31st of 51

$67.61

OR $126DC $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.