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Connecticut 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
$1,288.25 / $2,041.74 / $2,041.74
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,230.27 / $1,230.27 / $1,348.96
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$213.80 / $1,230.27 / $1,412.54
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,230.27 / $1,230.27 / $1,230.27
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,230.27 / $1,230.27 / $1,230.27
ConnectiCare
Facility/Professional
Professional
Modifier
Low / Median / High Price
$154.88 / $1,348.96 / $1,479.11
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$125.89 / $134.90 / $1,412.54