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Hawaii 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
Professional
Modifier
Low / Median / High Price
$1,230.27 / $1,230.27 / $1,288.25
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,174.90 / $1,230.27 / $1,380.38
HMSA
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,230.27 / $1,412.54 / $1,659.59
Kaiser Permanente
Facility/Professional
Professional
Modifier
Low / Median / High Price
$144.54 / $173.78 / $218.78
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$125.89 / $912.01 / $1,412.54