go back

Integra Dermal Regeneration Template (DRT) or Omnigraft

Michigan 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 $41 · 10th–90th $28$1260%20%40%10th90th$41Professionalmedian $28 · 10th–90th $24$1260%20%40%10th90th$28$20.0$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
$27.54
Median
$27.54
Typical High
$27.54
Aetna
Setting
Professional
Modifier
Global
Typical Low
$26.92
Median
$26.92
Typical High
$28.18
BCBS
Setting
Facility
Modifier
Global
Typical Low
$25.70
Median
$79.43
Typical High
$79.43
BCBS
Setting
Professional
Modifier
Global
Typical Low
$25.70
Median
$125.89
Typical High
$125.89
Cigna
Setting
Professional
Modifier
Global
Typical Low
$12.88
Median
$12.88
Typical High
$125.89
Health Alliance Plan
Setting
Facility
Modifier
Global
Typical Low
$40.74
Median
$85.11
Typical High
$229.09
Health Alliance Plan
Setting
Professional
Modifier
Global
Typical Low
$25.70
Median
$85.11
Typical High
$138.04
Priority Health
Setting
Professional
Modifier
Global
Typical Low
$12.88
Median
$12.88
Typical High
$12.88
United
Setting
Facility
Modifier
Global
Typical Low
$102.33
Median
$102.33
Typical High
$208.93
United
Setting
Professional
Modifier
Global
Typical Low
$83.18
Median
$125.89
Typical High
$125.89