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Wyoming 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
$128.82 / $128.82 / $128.82
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,230.27 / $1,230.27 / $1,445.44
BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,412.54 / $1,698.24 / $1,698.24
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,174.90 / $1,174.90 / $1,174.90
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,230.27 / $1,230.27 / $1,737.80
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$125.89 / $1,047.13 / $1,412.54