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Missouri 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
$1,230.27 / $1,288.25 / $1,778.28
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,230.27 / $1,230.27 / $1,479.11
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$97.72 / $120.23 / $1,548.82
BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$123.03 / $144.54 / $194.98
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
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,202.26 / $1,513.56 / $3,388.44
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,047.13 / $1,202.26 / $5,128.61
United
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,412.54 / $1,412.54 / $1,659.59
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$125.89 / $1,047.13 / $1,412.54