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Kansas 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
$1,732.20 / $1,732.20 / $1,732.20
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,237.28 / $1,262.03 / $1,732.20
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 / $1,237.28
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,226.15 / $1,680.00 / $1,816.62
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,190.44 / $1,190.44 / $5,119.78
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,055.97 / $1,237.28 / $1,392.81