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Ohio rates for HCPCS Q4117

HYALOMATRIX, per sq cm (add-on, list separately in addition to primary procedure)

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$21.88 / $21.88 / $21.88
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$21.88 / $22.91 / $26.30
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$16.98 / $21.88 / $63.10
CareSource
Facility/Professional
Facility
Modifier
Low / Median / High Price
$295.12 / $295.12 / $346.74
CareSource
Facility/Professional
Professional
Modifier
Low / Median / High Price
$295.12 / $295.12 / $295.12
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$24.55 / $24.55 / $24.55
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$24.55 / $24.55 / $24.55
Medical Mutual of Ohio
Facility/Professional
Facility
Modifier
Low / Median / High Price
$24.55 / $24.55 / $24.55
Medical Mutual of Ohio
Facility/Professional
Professional
Modifier
Low / Median / High Price
$24.55 / $24.55 / $28.84
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$18.62 / $33.11 / $131.83
SummaCare
Facility/Professional
Facility
Modifier
Low / Median / High Price
$134.90 / $144.54 / $158.49
SummaCare
Facility/Professional
Professional
Modifier
Low / Median / High Price
$22.39 / $34.67 / $70.79
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$28.84 / $28.84 / $125.89