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Ohio rates for HCPCS Q4126

MemoDerm, DermaSpan, TranZgraft or InteguPly, per sq cm (add-on, list separately in addition to primary procedure)

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$61.66 / $61.66 / $72.44
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$61.66 / $61.66 / $85.11
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$63.10 / $77.62 / $151.36
CareSource
Facility/Professional
Facility
Modifier
Low / Median / High Price
$63.10 / $63.10 / $63.10
CareSource
Facility/Professional
Professional
Modifier
Low / Median / High Price
$63.10 / $63.10 / $85.11
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$58.88 / $58.88 / $63.10
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$63.10 / $63.10 / $89.13
Medical Mutual of Ohio
Facility/Professional
Facility
Modifier
Low / Median / High Price
$58.88 / $58.88 / $63.10
Medical Mutual of Ohio
Facility/Professional
Professional
Modifier
Low / Median / High Price
$63.10 / $63.10 / $89.13
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$69.18 / $93.33 / $128.82
SummaCare
Facility/Professional
Facility
Modifier
Low / Median / High Price
$134.90 / $144.54 / $158.49
SummaCare
Facility/Professional
Professional
Modifier
Low / Median / High Price
$91.20 / $107.15 / $199.53
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$63.10 / $81.28 / $125.89