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Florida 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
$1,230.27 / $1,230.27 / $1,230.27
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,230.27 / $1,230.27 / $1,288.25
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 / $1,230.27
Florida Blue
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,412.54 / $1,412.54 / $1,412.54
Florida Blue
Facility/Professional
Professional
Modifier
Low / Median / High Price
$85.11 / $109.65 / $1,412.54
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$39.81 / $39.81 / $60.26
United
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,047.13 / $1,288.25 / $1,905.46
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$125.89 / $1,047.13 / $1,412.54
Wellpoint
Facility/Professional
Professional
Modifier
Low / Median / High Price
$134.90 / $1,148.15 / $1,148.15