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Oregon 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
$117.49 / $117.49 / $1,230.27
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,230.27 / $1,230.27 / $1,548.82
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,174.90 / $1,659.59 / $2,089.30
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,230.27 / $1,230.27 / $1,380.38
Kaiser Permanente
Facility/Professional
Professional
Modifier
Low / Median / High Price
$169.82 / $263.03 / $323.59
Moda Health
Facility/Professional
Facility
Modifier
Low / Median / High Price
$141.25 / $1,230.27 / $1,778.28
Moda Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$169.82 / $251.19 / $660.69
Pacific Source
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,202.26 / $1,230.27 / $1,862.09
Providence
Facility/Professional
Facility
Modifier
Low / Median / High Price
$234.42 / $1,230.27 / $1,862.09
Providence
Facility/Professional
Professional
Modifier
Low / Median / High Price
$79.43 / $125.89 / $1,819.70
Regence BlueShield
Facility/Professional
Professional
Modifier
Low / Median / High Price
$125.89 / $125.89 / $125.89
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$125.89 / $158.49 / $1,412.54