go back

Integra Dermal Regeneration Template (DRT) or Omnigraft

Wyoming 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 $257 · 10th–90th $129$4790%20%10th90th$257Professionalmedian $81 · 10th–90th $27$1290%20%10th90th$81$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. Small sample; interpret with caution. Need provider-level prices? Contact us.

Insurance Carrier
Aetna
Setting
Facility
Modifier
Global
Typical Low
$128.82
Median
$128.82
Typical High
$128.82
Aetna
Setting
Professional
Modifier
Global
Typical Low
$26.92
Median
$29.51
Typical High
$29.51
BCBS
Setting
Professional
Modifier
Global
Typical Low
$69.18
Median
$81.28
Typical High
$81.28
Cigna
Setting
Facility
Modifier
Global
Typical Low
$239.88
Median
$239.88
Typical High
$478.63
Cigna
Setting
Professional
Modifier
Global
Typical Low
$125.89
Median
$181.97
Typical High
$181.97
United
Setting
Facility
Modifier
Global
Typical Low
$208.93
Median
$257.04
Typical High
$281.84
United
Setting
Professional
Modifier
Global
Typical Low
$125.89
Median
$125.89
Typical High
$125.89