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Nationwide rates for HCPCS Q4205

Membrane Graft or Membrane Wrap, per sq cm (add-on, list separately in addition to primary procedure)

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$398.11 / $1,230.27 / $1,479.11
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,230.27 / $1,230.27 / $1,445.44
BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,230.27 / $1,513.56 / $3,630.78
BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$125.89 / $1,230.27 / $1,949.84
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,174.90 / $1,230.27 / $2,290.87
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,230.27 / $1,230.27 / $1,380.38
United
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,047.13 / $1,412.54 / $2,041.74
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$125.89 / $1,047.13 / $1,412.54