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Arkansas 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
$1,479.11 / $1,479.11 / $1,479.11
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,230.27 / $1,230.27 / $1,479.11
BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,348.96 / $1,348.96 / $1,348.96
BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,348.96 / $1,348.96 / $1,348.96
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,174.90 / $1,230.27 / $1,230.27
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,230.27 / $1,230.27 / $1,380.38
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$125.89 / $1,148.15 / $1,412.54