go back

Integra Dermal Regeneration Template (DRT) or Omnigraft

Tennessee 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 $195 · 10th–90th $47$7080%20%10th90th$195Professionalmedian $27 · 10th–90th $27$1260%50%90th$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
$26.92
Median
$26.92
Typical High
$46.77
Aetna
Setting
Professional
Modifier
Global
Typical Low
$26.92
Median
$26.92
Typical High
$28.18
BCBS
Setting
Professional
Modifier
Global
Typical Low
$74.13
Median
$79.43
Typical High
$79.43
Cigna
Setting
Facility
Modifier
Global
Typical Low
$138.04
Median
$186.21
Typical High
$223.87
Cigna
Setting
Professional
Modifier
Global
Typical Low
$125.89
Median
$125.89
Typical High
$125.89
Lucent Health
Setting
Facility
Modifier
Global
Typical Low
$707.95
Median
$707.95
Typical High
$707.95
Lucent Health
Setting
Professional
Modifier
Global
Typical Low
$660.69
Median
$660.69
Typical High
$660.69
United
Setting
Facility
Modifier
Global
Typical Low
$125.89
Median
$134.90
Typical High
$275.42
United
Setting
Professional
Modifier
Global
Typical Low
$112.20
Median
$125.89
Typical High
$125.89