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Integra Dermal Regeneration Template (DRT) or Omnigraft

Montana 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.

How much does Integra Dermal Regeneration Template (DRT) or Omnigraft cost?

$29.51

Typical negotiated rate. In Montana, July 2026.

Insurers have agreed to pay about $29.51 for this service. The price depends on where it is billed: about $29.51 from a physician practice, and about $26.30 from a hospital or other facility. The two figures are alternatives, not parts of one bill.

These are rates insurers have negotiated with providers, not the amount a patient is billed. What you owe depends on your plan's deductible and coinsurance. Based on rates published by 5 insurance carriers under federal price transparency rules.

Where it's billed changes the price

Billed byTypicalRange
Physician practiceA doctor's office, clinic or independent provider$29.51$26.92 to $38.02
FacilityA hospital or hospital-owned outpatient department$26.30$26.30 to $33.88

How much rates vary

Facilitymedian $26 · 10th to 90th $22 to $78Professionalmedian $30 · 10th to 90th $26 to $126
$10$20$50$100$200facility $26professional $30

Distribution of negotiated rates across all payers (price axis is log-scale). Each curve is scaled to its own total: facility and professional rates are different services, shown together to compare where they cluster. Need provider-level prices or 24+ months of history? Contact us.

Rates by insurance carrier

Insurance Carrier
Aetna
Setting
Professional
Modifier
Global
Typical Low
$26.92
Median
$29.51
Typical High
$33.88
Cigna
Setting
Facility
Modifier
Global
Typical Low
$26.30
Median
$26.30
Typical High
$204.17
Cigna
Setting
Professional
Modifier
Global
Typical Low
$26.30
Median
$125.89
Typical High
$125.89
MountainHealth Co-op
Setting
Facility
Modifier
Global
Typical Low
$22.39
Median
$26.30
Typical High
$48.98
MountainHealth Co-op
Setting
Professional
Modifier
Global
Typical Low
$22.39
Median
$26.30
Typical High
$48.98
Providence
Setting
Facility
Modifier
Global
Typical Low
$16.22
Median
$28.18
Typical High
$181.97
Providence
Setting
Professional
Modifier
Global
Typical Low
$26.30
Median
$67.61
Typical High
$125.89
United
Setting
Professional
Modifier
Global
Typical Low
$125.89
Median
$125.89
Typical High
$125.89

Where Montana sits

The same service costs 3.3 times more in Minnesota than in West Virginia. Every bar is a state, most expensive first. Touch or drag across it to read any state, then open that state for its carriers and full range.

Montana· 16th of 51

$29.51

MN $89.13WV $26.92

Median negotiated rate in each state, from every insurer that publishes one. States where no insurer publishes a rate for this service are not shown.