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Tennessee 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
$1,190.44 / $1,237.28 / $2,083.27
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,237.28 / $1,237.28 / $1,299.15
BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,055.97 / $1,190.44 / $1,347.67
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,237.28 / $1,237.28 / $1,237.28
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,237.28 / $1,237.28 / $1,237.28
Lucent Health
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,428.00 / $2,408.92 / $5,119.78
Lucent Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$5,119.78 / $5,119.78 / $5,563.22
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,055.97 / $1,237.28 / $1,237.28