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Idaho 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 / $1,190.44 / $1,190.44
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,190.44 / $1,361.01 / $1,546.61
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,167.25 / $1,237.28 / $1,237.28
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,237.28 / $1,237.28 / $1,237.28
Moda Health
Facility/Professional
Facility
Modifier
Low / Median / High Price
$106.56 / $1,546.61 / $1,979.66
Moda Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,237.28 / $1,311.52 / $1,546.60
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$30.00 / $78.00 / $2,059.14
Regence BlueShield
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,484.74 / $1,484.74 / $1,484.74
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,237.28 / $1,237.28 / $1,237.28