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Ohio rates for HCPCS Q4122

DermACELL, DermACELL AWM or DermACELL AWM Porous, per sq cm (add-on, list separately in addition to primary procedure)

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$95.50 / $95.50 / $95.50
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$95.50 / $100.00 / $102.33
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$41.69 / $52.48 / $154.88
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$102.33 / $102.33 / $102.33
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$102.33 / $102.33 / $102.33
Medical Mutual of Ohio
Facility/Professional
Facility
Modifier
Low / Median / High Price
$102.33 / $102.33 / $102.33
Medical Mutual of Ohio
Facility/Professional
Professional
Modifier
Low / Median / High Price
$102.33 / $102.33 / $120.23
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$39.81 / $50.12 / $60.26
SummaCare
Facility/Professional
Facility
Modifier
Low / Median / High Price
$134.90 / $144.54 / $158.49
SummaCare
Facility/Professional
Professional
Modifier
Low / Median / High Price
$123.03 / $144.54 / $269.15
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$109.65 / $109.65 / $125.89