go back

Montana 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
$1,230.27 / $1,230.27 / $1,479.11
BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$64,565.42 / $83,176.38 / $95,499.26
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,202.26 / $1,202.26 / $1,230.27
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,202.26 / $1,230.27 / $1,737.80
MountainHealth Co-op
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,318.26 / $1,318.26 / $2,884.03
MountainHealth Co-op
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,318.26 / $1,318.26 / $2,884.03
Providence
Facility/Professional
Facility
Modifier
Low / Median / High Price
$181.97 / $1,230.27 / $2,089.30
Providence
Facility/Professional
Professional
Modifier
Low / Median / High Price
$79.43 / $125.89 / $1,445.44
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$125.89 / $165.96 / $1,412.54