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Ohio rates for HCPCS Q4157

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

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$165.96 / $165.96 / $165.96
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$165.96 / $173.78 / $177.83
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.02 / $147.91 / $199.53
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$177.83 / $177.83 / $177.83
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$177.83 / $177.83 / $177.83
Medical Mutual of Ohio
Facility/Professional
Facility
Modifier
Low / Median / High Price
$177.83 / $177.83 / $199.53
Medical Mutual of Ohio
Facility/Professional
Professional
Modifier
Low / Median / High Price
$177.83 / $177.83 / $208.93
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
$125.89 / $204.17 / $204.17