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Colorado 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
$1,190.44 / $1,237.28 / $1,237.28
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,237.28 / $1,237.28 / $1,274.40
Anthem BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$402.90 / $402.90 / $402.90
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$402.90 / $402.90 / $402.90
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,167.25 / $1,167.25 / $1,890.00
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,237.28 / $1,237.28 / $1,237.28
Denver HMP
Facility/Professional
Facility
Modifier
Low / Median / High Price
$106.56 / $1,311.52 / $2,203.35
Kaiser Permanente
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,348.64 / $1,361.01 / $1,756.94
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,055.97 / $1,237.28 / $1,237.28