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Integra Dermal Regeneration Template (DRT) or Omnigraft

Nebraska 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 $30 · 10th–90th $26$3090%20%10th90th$30Professionalmedian $28 · 10th–90th $27$1120%50%10th90th$28$20.0$100.0$500.0$2.0K

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
$4,786.30
Aetna
Setting
Professional
Modifier
Global
Typical Low
$26.92
Median
$26.92
Typical High
$44.67
BCBS
Setting
Facility
Modifier
Global
Typical Low
$22.91
Median
$28.84
Typical High
$30.20
BCBS
Setting
Professional
Modifier
Global
Typical Low
$28.84
Median
$28.84
Typical High
$30.20
Cigna
Setting
Facility
Modifier
Global
Typical Low
$23.44
Median
$190.55
Typical High
$229.09
Cigna
Setting
Professional
Modifier
Global
Typical Low
$23.44
Median
$31.62
Typical High
$125.89
Medica
Setting
Facility
Modifier
Global
Typical Low
$26.30
Median
$38.02
Typical High
$52.48
Medica
Setting
Professional
Modifier
Global
Typical Low
$23.44
Median
$26.30
Typical High
$57.54
Midlands
Setting
Professional
Modifier
Global
Typical Low
$28.18
Median
$31.62
Typical High
$51.29
Midlands
Setting
Facility
Modifier
Global
Typical Low
$21.38
Median
$204.17
Typical High
$309.03
Midlands
Setting
Professional
Modifier
Global
Typical Low
$34.67
Median
$45.71
Typical High
$64.57
United
Setting
Facility
Modifier
Global
Typical Low
$102.33
Median
$134.90
Typical High
$338.84
United
Setting
Professional
Modifier
Global
Typical Low
$120.23
Median
$125.89
Typical High
$141.25