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Integra Dermal Regeneration Template (DRT) or Omnigraft

Wisconsin 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 $50 · 10th–90th $27$4900%20%10th90th$50Professionalmedian $68 · 10th–90th $27$1410%20%10th90th$68$5.0$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
$27.54
Median
$27.54
Typical High
$27.54
Aetna
Setting
Professional
Modifier
Global
Typical Low
$26.92
Median
$27.54
Typical High
$32.36
Anthem BCBS
Setting
Professional
Modifier
Global
Typical Low
$36.31
Median
$67.61
Typical High
$97.72
Cigna
Setting
Facility
Modifier
Global
Typical Low
$56.23
Median
$75.86
Typical High
$199.53
Cigna
Setting
Professional
Modifier
Global
Typical Low
$23.44
Median
$69.18
Typical High
$125.89
DeanCare
Setting
Facility
Modifier
Global
Typical Low
$26.92
Median
$27.54
Typical High
$58.88
DeanCare
Setting
Professional
Modifier
Global
Typical Low
$25.12
Median
$25.12
Typical High
$29.51
Medica
Setting
Facility
Modifier
Global
Typical Low
$26.30
Median
$26.92
Typical High
$75.86
Medica
Setting
Professional
Modifier
Global
Typical Low
$26.30
Median
$26.30
Typical High
$120.23
Molina
Setting
Professional
Modifier
Global
Typical Low
$32.36
Median
$33.11
Typical High
$70.79
Network Health
Setting
Facility
Modifier
Global
Typical Low
$26.92
Median
$26.92
Typical High
$31.62
Network Health
Setting
Professional
Modifier
Global
Typical Low
$30.90
Median
$32.36
Typical High
$54.95
Prevea360
Setting
Facility
Modifier
Global
Typical Low
$26.92
Median
$27.54
Typical High
$58.88
Quartz
Setting
Professional
Modifier
Global
Typical Low
$107.15
Median
$229.09
Typical High
$416.87
Quartz
Setting
Facility
Modifier
Global
Typical Low
$489.78
Median
$489.78
Typical High
$707.95
Quartz
Setting
Professional
Modifier
Global
Typical Low
$125.89
Median
$125.89
Typical High
$660.69
Security Health
Setting
Professional
Modifier
Global
Typical Low
$36.31
Median
$44.67
Typical High
$93.33
United
Setting
Facility
Modifier
Global
Typical Low
$125.89
Median
$125.89
Typical High
$295.12
United
Setting
Professional
Modifier
Global
Typical Low
$125.89
Median
$125.89
Typical High
$144.54