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Integra Dermal Regeneration Template (DRT) or Omnigraft

Minnesota 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 $59 · 10th–90th $23$2570%10%10th90th$59Professionalmedian $102 · 10th–90th $20$1260%20%10th90th$102$0.2$1.0$5.0$20.0$100.0$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
$26.92
Aetna
Setting
Professional
Modifier
Global
Typical Low
$26.92
Median
$26.92
Typical High
$30.90
BCBS
Setting
Facility
Modifier
Global
Typical Low
$23.44
Median
$42.66
Typical High
$257.04
BCBS
Setting
Professional
Modifier
Global
Typical Low
$19.95
Median
$107.15
Typical High
$125.89
Cigna
Setting
Facility
Modifier
Global
Typical Low
$36.31
Median
$63.10
Typical High
$87.10
Cigna
Setting
Professional
Modifier
Global
Typical Low
$23.99
Median
$27.54
Typical High
$30.20
Health Partners
Setting
Facility
Modifier
Global
Typical Low
$42.66
Median
$60.26
Typical High
$89.13
Health Partners
Setting
Professional
Modifier
Global
Typical Low
$23.44
Median
$23.44
Typical High
$32.36
Medica
Setting
Facility
Modifier
Global
Typical Low
$22.39
Median
$26.30
Typical High
$57.54
Medica
Setting
Professional
Modifier
Global
Typical Low
$25.12
Median
$26.30
Typical High
$47.86
United
Setting
Professional
Modifier
Global
Typical Low
$30.90
Median
$125.89
Typical High
$239.88