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Oklahoma 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
$1,336.27 / $1,336.27 / $1,336.27
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,249.66 / $1,336.27 / $1,336.27
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,167.25 / $1,167.25 / $1,237.28
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,237.28 / $1,237.28 / $1,237.28
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,285.68 / $1,349.96 / $1,979.65
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,055.97 / $1,190.44 / $5,119.78
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,055.97 / $1,237.28 / $1,364.35