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Integra Dermal Regeneration Template (DRT) or Omnigraft

New Mexico 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 $37 · 10th–90th $14$2090%10%20%10th90th$37Professionalmedian $27 · 10th–90th $27$1260%50%90th$27$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
$33.88
Cigna
Setting
Facility
Modifier
Global
Typical Low
$125.89
Median
$125.89
Typical High
$257.04
Cigna
Setting
Professional
Modifier
Global
Typical Low
$125.89
Median
$125.89
Typical High
$125.89
Molina
Setting
Professional
Modifier
Global
Typical Low
$30.20
Median
$34.67
Typical High
$64.57
Providence
Setting
Facility
Modifier
Global
Typical Low
$13.49
Median
$31.62
Typical High
$177.83
Providence
Setting
Professional
Modifier
Global
Typical Low
$40.74
Median
$125.89
Typical High
$125.89
United
Setting
Facility
Modifier
Global
Typical Low
$120.23
Median
$208.93
Typical High
$208.93
United
Setting
Professional
Modifier
Global
Typical Low
$125.89
Median
$125.89
Typical High
$125.89