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Michigan 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
$1,274.40 / $1,274.40 / $1,274.40
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,237.28 / $1,274.40 / $1,274.40
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,140.47 / $1,237.28 / $1,366.41
Health Alliance Plan
Facility/Professional
Facility
Modifier
Low / Median / High Price
$356.40 / $1,237.28 / $1,274.40
Health Alliance Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,237.28 / $1,237.28 / $1,484.73
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$30.00 / $1,425.55 / $1,855.92
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,055.97 / $1,237.28 / $1,312.75