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North Carolina 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
$402.90 / $402.90 / $402.90
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$402.90 / $402.90 / $1,299.15
BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$747.59 / $805.36 / $885.90
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,167.25 / $1,237.28 / $1,237.28
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,237.28 / $1,237.28 / $1,680.00
Medcost
Facility/Professional
Facility
Modifier
Low / Median / High Price
$402.90 / $1,596.00 / $1,848.00
Medcost
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,596.00 / $1,596.00 / $1,664.27
Oscar Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$149.69 / $149.69 / $149.69
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,055.97 / $1,237.28 / $1,608.46
Wellcare
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,645.82 / $2,408.92 / $5,119.78
Wellcare
Facility/Professional
Professional
Modifier
Low / Median / High Price
$5,119.78 / $5,119.78 / $5,563.22