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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.

Facilitymedian $26 · 10th–90th $22$780%20%40%10th90th$26Professionalmedian $30 · 10th–90th $26$1260%20%10th90th$30$10.0$20.0$50.0$100.0$200.0

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
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