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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
$117.49 / $117.49 / $117.49
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$398.11 / $1,230.27 / $1,479.11
BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,412.54 / $1,412.54 / $1,412.54
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
Moda Health
Facility/Professional
Facility
Modifier
Low / Median / High Price
$281.84 / $1,548.82 / $2,187.76
Moda Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$165.96 / $223.87 / $331.13
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$30.20 / $30.20 / $77.62
Regence BlueShield
Facility/Professional
Professional
Modifier
Low / Median / High Price
$125.89 / $151.36 / $151.36
Select Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$114.82 / $117.49 / $123.03
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$125.89 / $125.89 / $1,412.54