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Washington, DC 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
$1,237.28 / $1,237.28 / $1,237.28
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,237.28 / $1,237.28 / $1,237.28
CareFirst
Facility/Professional
Professional
Modifier
Low / Median / High Price
$336.60 / $336.60 / $336.60
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,167.25 / $1,167.25 / $1,237.28
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,237.28 / $1,237.28 / $1,575.79
Kaiser Permanente
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,051.69 / $1,051.69 / $1,511.64
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,055.97 / $1,237.28 / $2,005.36