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Arizona 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
$1,361.01 / $1,361.01 / $1,361.01
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,237.28 / $1,249.66 / $1,361.01
BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$851.54 / $2,011.75 / $4,975.10
BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$864.84 / $1,064.42 / $2,514.67
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,167.25 / $1,237.28 / $1,237.28
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,237.28 / $1,237.28 / $1,237.28
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$106.56 / $1,309.48 / $2,658.24
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,190.44 / $1,190.44 / $2,583.25
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,055.97 / $1,237.28 / $1,237.28