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Washington rates for HCPCS Q4205

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

Facilitymedian $1,230 · 10th–90th $347$2,8840%20%10th90th$1,230Professionalmedian $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. Need provider-level prices? Contact us.

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Typical Low / Median / Typical High
$1,348.96 / $1,348.96 / $1,348.96
Aetna
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$1,230.27 / $1,230.27 / $1,548.82
Asuris Northwest Health
Facility/Professional
Facility
Modifier
Typical Low / Median / Typical High
$125.89 / $125.89 / $125.89
Asuris Northwest Health
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$125.89 / $125.89 / $141.25
Cigna
Facility/Professional
Facility
Modifier
Typical Low / Median / Typical High
$169.82 / $169.82 / $588.84
Cigna
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$125.89 / $125.89 / $131.83
Kaiser Permanente
Facility/Professional
Facility
Modifier
Typical Low / Median / Typical High
$380.19 / $1,659.59 / $3,311.31
Kaiser Permanente
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$2,454.71 / $2,818.38 / $3,630.78
Molina
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$30.20 / $50.12 / $75.86
Pacific Source
Facility/Professional
Facility
Modifier
Typical Low / Median / Typical High
$1,202.26 / $1,230.27 / $1,318.26
Premera BCBS
Facility/Professional
Facility
Modifier
Typical Low / Median / Typical High
$1,380.38 / $1,380.38 / $1,412.54
Premera BCBS
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$1,412.54 / $1,412.54 / $1,412.54
Regence BlueShield
Facility/Professional
Facility
Modifier
Typical Low / Median / Typical High
$125.89 / $125.89 / $125.89
Regence BlueShield
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$123.03 / $125.89 / $141.25
United
Facility/Professional
Facility
Modifier
Typical Low / Median / Typical High
$102.33 / $102.33 / $1,047.13
United
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$125.89 / $125.89 / $1,047.13
Wellpoint
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$134.90 / $154.88 / $295.12