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North Dakota 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
$1,237.28 / $1,237.28 / $1,237.28
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,237.28 / $1,237.28 / $1,249.66
BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,115.79 / $1,255.08 / $1,359.12
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$2,091.08 / $2,091.08 / $2,404.73
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,075.91 / $1,237.28 / $1,344.89
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$133.03 / $1,428.00 / $2,227.10
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,055.97 / $1,190.44 / $1,333.29
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,237.28 / $1,237.28 / $1,343.75