go back

Integra Dermal Regeneration Template (DRT) or Omnigraft

Massachusetts 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 $93 · 10th–90th $60$2340%20%10th90th$93Professionalmedian $27 · 10th–90th $27$1260%50%90th$27$10.0$50.0$200.0$1.0K$5.0K$20.0K

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
$26.92
Aetna
Setting
Professional
Modifier
Global
Typical Low
$26.92
Median
$26.92
Typical High
$32.36
AllWays Health Partners
Setting
Facility
Modifier
Global
Typical Low
$79.43
Median
$125.89
Typical High
$707.95
AllWays Health Partners
Setting
Professional
Modifier
Global
Typical Low
$102.33
Median
$125.89
Typical High
$245.47
BCBS
Setting
Facility
Modifier
Global
Typical Low
$77.62
Median
$77.62
Typical High
$154.88
Cigna
Setting
Facility
Modifier
Global
Typical Low
$151.36
Median
$229.09
Typical High
$549.54
Cigna
Setting
Professional
Modifier
Global
Typical Low
$125.89
Median
$125.89
Typical High
$125.89
Fallon Health
Setting
Facility
Modifier
Global
Typical Low
$93.33
Median
$181.97
Typical High
$1,995.26
Fallon Health
Setting
Professional
Modifier
Global
Typical Low
$128.82
Median
$181.97
Typical High
$275.42
Harvard Pilgrim
Setting
Professional
Modifier
Global
Typical Low
$26.92
Median
$26.92
Typical High
$48.98
Health New England
Setting
Facility
Modifier
Global
Typical Low
$12,882.50
Median
$12,882.50
Typical High
$12,882.50
Mass General Brigham
Setting
Facility
Modifier
Global
Typical Low
$79.43
Median
$125.89
Typical High
$707.95
Mass General Brigham
Setting
Professional
Modifier
Global
Typical Low
$102.33
Median
$125.89
Typical High
$245.47
United
Setting
Facility
Modifier
Global
Typical Low
$125.89
Median
$208.93
Typical High
$275.42
United
Setting
Professional
Modifier
Global
Typical Low
$25.12
Median
$26.92
Typical High
$125.89