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South 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
$1,288.25 / $1,737.80 / $1,737.80
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,230.27 / $1,230.27 / $1,288.25
BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$117.49 / $165.96 / $1,862.09
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,174.90 / $1,230.27 / $1,230.27
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,230.27 / $1,230.27 / $1,230.27
Medcost
Facility/Professional
Facility
Modifier
Low / Median / High Price
$407.38 / $1,288.25 / $1,995.26
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$30.20 / $389.05 / $1,230.27
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$125.89 / $1,047.13 / $1,412.54