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Integra Dermal Regeneration Template (DRT) or Omnigraft

Texas 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 $81 · 10th–90th $27$2570%10%20%10th90th$81Professionalmedian $27 · 10th–90th $27$1260%50%90th$27$2.0$10.0$50.0$200.0$1.0K

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
$47.86
Aetna
Setting
Professional
Modifier
Global
Typical Low
$26.92
Median
$26.92
Typical High
$28.84
BCBS
Setting
Facility
Modifier
Global
Typical Low
$46.77
Median
$112.20
Typical High
$208.93
BCBS
Setting
Professional
Modifier
Global
Typical Low
$25.70
Median
$25.70
Typical High
$25.70
Christus
Setting
Facility
Modifier
Global
Typical Low
$26.92
Median
$120.23
Typical High
$125.89
Cigna
Setting
Facility
Modifier
Global
Typical Low
$125.89
Median
$302.00
Typical High
$851.14
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
Moda Health
Setting
Facility
Modifier
Global
Typical Low
$20.42
Median
$26.92
Typical High
$100.00
Moda Health
Setting
Professional
Modifier
Global
Typical Low
$147.91
Median
$190.55
Typical High
$234.42
Molina
Setting
Professional
Modifier
Global
Typical Low
$25.70
Median
$29.51
Typical High
$33.11
Providence
Setting
Facility
Modifier
Global
Typical Low
$26.92
Median
$38.90
Typical High
$194.98
Providence
Setting
Professional
Modifier
Global
Typical Low
$125.89
Median
$125.89
Typical High
$125.89
United
Setting
Facility
Modifier
Global
Typical Low
$102.33
Median
$125.89
Typical High
$208.93
United
Setting
Professional
Modifier
Global
Typical Low
$114.82
Median
$125.89
Typical High
$125.89
Wellpoint
Setting
Professional
Modifier
Global
Typical Low
$30.20
Median
$120.23
Typical High
$169.82