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Integra Dermal Regeneration Template (DRT) or Omnigraft

South 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$810%50%10th90th$27Professionalmedian $27 · 10th–90th $23$910%20%40%10th90th$27$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
$81.28
Aetna
Setting
Professional
Modifier
Global
Typical Low
$26.92
Median
$26.92
Typical High
$33.88
Cigna
Setting
Facility
Modifier
Global
Typical Low
$22.91
Median
$31.62
Typical High
$169.82
Cigna
Setting
Professional
Modifier
Global
Typical Low
$23.44
Median
$29.51
Typical High
$29.51
Medica
Setting
Facility
Modifier
Global
Typical Low
$26.30
Median
$43.65
Typical High
$75.86
Medica
Setting
Professional
Modifier
Global
Typical Low
$23.44
Median
$26.30
Typical High
$134.90
Midlands
Setting
Professional
Modifier
Global
Typical Low
$28.18
Median
$31.62
Typical High
$31.62
Midlands
Setting
Facility
Modifier
Global
Typical Low
$22.91
Median
$169.82
Typical High
$204.17
Midlands
Setting
Professional
Modifier
Global
Typical Low
$45.71
Median
$45.71
Typical High
$91.20
Sanford Health Plan
Setting
Professional
Modifier
Global
Typical Low
$67.61
Median
$67.61
Typical High
$67.61
United
Setting
Professional
Modifier
Global
Typical Low
$30.20
Median
$125.89
Typical High
$239.88
Wellmark
Setting
Facility
Modifier
Global
Typical Low
$26.92
Median
$26.92
Typical High
$26.92
Wellmark
Setting
Professional
Modifier
Global
Typical Low
$26.92
Median
$26.92
Typical High
$26.92