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Integra Dermal Regeneration Template (DRT) or Omnigraft

West 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 $27 · 10th–90th $27$1740%50%90th$27Professionalmedian $27 · 10th–90th $27$1260%50%90th$27$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
$77.62
Aetna
Setting
Professional
Modifier
Global
Typical Low
$26.92
Median
$26.92
Typical High
$77.62
CareSource
Setting
Facility
Modifier
Global
Typical Low
$26.92
Median
$26.92
Typical High
$26.92
CareSource
Setting
Professional
Modifier
Global
Typical Low
$26.92
Median
$26.92
Typical High
$26.92
Cigna
Setting
Facility
Modifier
Global
Typical Low
$125.89
Median
$173.78
Typical High
$239.88
Cigna
Setting
Professional
Modifier
Global
Typical Low
$125.89
Median
$125.89
Typical High
$616.60
United
Setting
Facility
Modifier
Global
Typical Low
$208.93
Median
$208.93
Typical High
$208.93
United
Setting
Professional
Modifier
Global
Typical Low
$102.33
Median
$125.89
Typical High
$134.90