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Utah rates for HCPCS Q4205

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

Facilitymedian $1,445 · 10th–90th $1,445–$1,6220%50%90th$1,445Professionalmedian $1,230 · 10th–90th $126–$1,5490%20%10th90th$1,230$50.0$100.0$200.0$500.0$1.0K$2.0K$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. Small sample — interpret with caution. Need provider-level prices? Contact us.

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Typical Low / Median / Typical High
$1,445.44 / $1,445.44 / $1,445.44
Aetna
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$398.11 / $1,258.93 / $1,548.82
Cigna
Facility/Professional
Facility
Modifier
Typical Low / Median / Typical High
$446.68 / $1,513.56 / $1,862.09
Cigna
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$125.89 / $125.89 / $125.89
Molina
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$30.20 / $44.67 / $60.26
Regence BlueShield
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$112.20 / $141.25 / $162.18
Select Health
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$120.23 / $120.23 / $125.89
U of Utah Health Plan
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$83.18 / $169.82 / $269.15
United
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$125.89 / $125.89 / $125.89