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Ohio rates for HCPCS Q4205

Membrane Graft or Membrane Wrap, per sq cm (add-on, list separately in addition to primary procedure)

Facilitymedian $1,230 · 10th–90th $102$1,4450%20%10th90th$1,230Professionalmedian $1,230 · 10th–90th $148$1,6600%20%40%10th90th$1,230$2.0$10.0$50.0$200.0$1.0K$5.0K

Distribution of negotiated rates across all payers (price axis is log-scale). Facility and professional rates are different services and are charted separately. Need provider-level prices? Contact us.

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Typical Low / Median / Typical High
$1,230.27 / $1,230.27 / $1,445.44
Aetna
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$1,230.27 / $1,230.27 / $1,348.96
Anthem BCBS
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$190.55 / $1,348.96 / $2,137.96
CareSource
Facility/Professional
Facility
Modifier
Typical Low / Median / Typical High
$1,230.27 / $1,230.27 / $1,230.27
CareSource
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$1,230.27 / $1,230.27 / $1,659.59
Cigna
Facility/Professional
Facility
Modifier
Typical Low / Median / Typical High
$239.88 / $269.15 / $416.87
Cigna
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$125.89 / $125.89 / $181.97
Medical Mutual of Ohio
Facility/Professional
Facility
Modifier
Typical Low / Median / Typical High
$1,174.90 / $1,174.90 / $1,230.27
Medical Mutual of Ohio
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$1,230.27 / $1,230.27 / $1,698.24
Molina
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$39.81 / $60.26 / $1,348.96
SummaCare
Facility/Professional
Facility
Modifier
Typical Low / Median / Typical High
$134.90 / $144.54 / $158.49
SummaCare
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$117.49 / $144.54 / $269.15
United
Facility/Professional
Facility
Modifier
Typical Low / Median / Typical High
$102.33 / $102.33 / $2,290.87
United
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$125.89 / $125.89 / $1,047.13