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Maine 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
$1,237.28 / $1,286.78 / $1,286.78
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,237.28 / $1,237.28 / $1,237.28
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,237.28 / $1,237.28 / $1,237.28
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,237.28 / $1,237.28 / $1,237.28
Harvard Pilgrim
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,237.28 / $1,237.28 / $1,237.28
Martin's Point
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,237.28 / $1,286.78 / $1,286.78
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,237.28 / $1,237.28 / $1,855.92