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Utah rates for HCPCS Q4205

Membrane Graft Or Membrane Wrap Per Square Centimeter

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,435.25 / $1,435.25 / $1,435.25
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,237.28 / $1,361.01 / $1,546.61
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,237.28 / $1,531.57 / $2,139.69
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,237.28 / $1,237.28 / $1,237.28
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$30.00 / $45.00 / $60.00
Regence BlueShield
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,224.91 / $1,361.01 / $1,361.01
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,237.28 / $1,237.28 / $1,237.28