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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.

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

$26.92

Typical negotiated rate. In Pennsylvania, July 2026.

Insurers have agreed to pay about $26.92 for this service. The price depends on where it is billed: about $26.92 from a physician practice, and about $26.92 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$26.92$26.92 to $29.51
FacilityA hospital or hospital-owned outpatient department$26.92$26.92 to $74.13

How much rates vary

Facilitymedian $27 · 10th to 90th $27 to $447Professionalmedian $27 · 10th to 90th $27 to $126
$10.0$100.0$1.0K$10.0Kfacility $27professional $27

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
$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

Where Pennsylvania sits

The same service costs 3.3 times more in Minnesota than in West Virginia. Every bar is a state, most expensive first. Pick one to see its carriers and full range.

Pennsylvania $26.92 · 37th of 51
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.