go back

Integra Dermal Regeneration Template (DRT) or Omnigraft

Virginia 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 $28 · 10th–90th $27$1860%20%10th90th$28Professionalmedian $28 · 10th–90th $27$1260%20%10th90th$28$2.0$10.0$50.0$200.0

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
$28.18
Typical High
$28.18
Aetna
Setting
Professional
Modifier
Global
Typical Low
$26.92
Median
$26.92
Typical High
$33.88
Anthem BCBS
Setting
Professional
Modifier
Global
Typical Low
$64.57
Median
$64.57
Typical High
$114.82
CareFirst
Setting
Professional
Modifier
Global
Typical Low
$11.75
Median
$11.75
Typical High
$40.74
Cigna
Setting
Facility
Modifier
Global
Typical Low
$177.83
Median
$251.19
Typical High
$316.23
Cigna
Setting
Professional
Modifier
Global
Typical Low
$125.89
Median
$125.89
Typical High
$125.89
Kaiser Permanente
Setting
Professional
Modifier
Global
Typical Low
$104.71
Median
$131.83
Typical High
$239.88
Medcost
Setting
Professional
Modifier
Global
Typical Low
$11.75
Median
$11.75
Typical High
$11.75
Medcost
Setting
Facility
Modifier
Global
Typical Low
$26.92
Median
$28.18
Typical High
$81.28
Medcost
Setting
Professional
Modifier
Global
Typical Low
$26.92
Median
$26.92
Typical High
$109.65
Sentara
Setting
Facility
Modifier
Global
Typical Low
$24.55
Median
$31.62
Typical High
$77.62
Sentara
Setting
Professional
Modifier
Global
Typical Low
$24.55
Median
$31.62
Typical High
$77.62
United
Setting
Facility
Modifier
Global
Typical Low
$125.89
Median
$154.88
Typical High
$338.84
United
Setting
Professional
Modifier
Global
Typical Low
$112.20
Median
$125.89
Typical High
$125.89