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Integra Dermal Regeneration Template (DRT) or Omnigraft

Utah 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?

$30.90

Typical negotiated rate. In Utah, July 2026.

Insurers have agreed to pay about $30.90 for this service. The price depends on where it is billed: about $30.90 from a physician practice, and about $30.90 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 7 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$30.90$26.92 to $112
FacilityA hospital or hospital-owned outpatient department$30.90$30.90 to $33.11

How much rates vary

Facilitymedian $31 · 10th to 90th $31 to $120Professionalmedian $31 · 10th to 90th $27 to $126
$50$100$200$500facility $31professional $31

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
$30.90
Median
$30.90
Typical High
$30.90
Aetna
Setting
Professional
Modifier
Global
Typical Low
$26.92
Median
$29.51
Typical High
$33.88
Cigna
Setting
Facility
Modifier
Global
Typical Low
$31.62
Median
$35.48
Typical High
$144.54
Cigna
Setting
Professional
Modifier
Global
Typical Low
$125.89
Median
$125.89
Typical High
$125.89
Molina
Setting
Professional
Modifier
Global
Typical Low
$25.70
Median
$28.84
Typical High
$75.86
Regence BlueShield
Setting
Professional
Modifier
Global
Typical Low
$123.03
Median
$141.25
Typical High
$162.18
Select Health
Setting
Facility
Modifier
Global
Typical Low
$120.23
Median
$120.23
Typical High
$120.23
Select Health
Setting
Professional
Modifier
Global
Typical Low
$56.23
Median
$120.23
Typical High
$144.54
U of Utah Health Plan
Setting
Professional
Modifier
Global
Typical Low
$33.88
Median
$144.54
Typical High
$245.47
United
Setting
Professional
Modifier
Global
Typical Low
$125.89
Median
$125.89
Typical High
$125.89

Where Utah sits

The same service costs 3.3 times more in Minnesota than in West Virginia. 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.

Utah· 13th of 51

$30.90

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.