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Integra Dermal Regeneration Template (DRT) or Omnigraft

South Carolina 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 $34 · 10th–90th $27$1820%10%20%10th90th$34Professionalmedian $27 · 10th–90th $24$1260%20%40%10th90th$27$10.0$20.0$50.0$100.0$200.0$500.0

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
$28.18
Median
$28.18
Typical High
$38.02
Aetna
Setting
Professional
Modifier
Global
Typical Low
$23.99
Median
$26.92
Typical High
$29.51
BCBS
Setting
Facility
Modifier
Global
Typical Low
$38.02
Median
$50.12
Typical High
$83.18
BCBS
Setting
Professional
Modifier
Global
Typical Low
$38.90
Median
$48.98
Typical High
$144.54
Cigna
Setting
Facility
Modifier
Global
Typical Low
$144.54
Median
$181.97
Typical High
$323.59
Cigna
Setting
Professional
Modifier
Global
Typical Low
$125.89
Median
$125.89
Typical High
$125.89
Medcost
Setting
Facility
Modifier
Global
Typical Low
$18.62
Median
$29.51
Typical High
$89.13
Molina
Setting
Professional
Modifier
Global
Typical Low
$26.92
Median
$47.86
Typical High
$83.18
United
Setting
Facility
Modifier
Global
Typical Low
$102.33
Median
$125.89
Typical High
$208.93
United
Setting
Professional
Modifier
Global
Typical Low
$104.71
Median
$125.89
Typical High
$125.89