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Integra Dermal Regeneration Template (DRT) or Omnigraft

North Dakota 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 $27 · 10th–90th $26$440%50%10th90th$27Professionalmedian $60 · 10th–90th $27$790%20%10th90th$60$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
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
$50.12
BCBS
Setting
Professional
Modifier
Global
Typical Low
$53.70
Median
$61.66
Typical High
$79.43
Cigna
Setting
Facility
Modifier
Global
Typical Low
$37.15
Median
$37.15
Typical High
$42.66
Cigna
Setting
Professional
Modifier
Global
Typical Low
$23.44
Median
$29.51
Typical High
$125.89
Medica
Setting
Facility
Modifier
Global
Typical Low
$26.30
Median
$30.20
Typical High
$48.98
Medica
Setting
Professional
Modifier
Global
Typical Low
$23.44
Median
$26.30
Typical High
$29.51
United
Setting
Professional
Modifier
Global
Typical Low
$51.29
Median
$125.89
Typical High
$239.88