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California rates for HCPCS Q4221

Amnio Wrap2, per sq cm (add-on, list separately in addition to primary procedure)

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,961.00 / $1,961.00 / $1,980.61
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,961.00 / $1,961.00 / $2,157.10
Anthem BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,911.19 / $2,275.54 / $3,850.03
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,961.00 / $2,072.00 / $4,625.00
Blue Shield
Facility/Professional
Facility
Modifier
Low / Median / High Price
$100.00 / $100.00 / $100.00
Blue Shield
Facility/Professional
Professional
Modifier
Low / Median / High Price
$100.00 / $100.00 / $1,568.80
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,850.00 / $1,850.00 / $1,961.00
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,961.00 / $1,961.00 / $2,127.50
Contra Costa Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,696.00 / $1,696.00 / $2,035.20
Kaiser Permanente
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,764.90 / $2,451.25 / $4,314.20
Lucent Health
Facility/Professional
Facility
Modifier
Low / Median / High Price
$2,608.50 / $5,700.00 / $6,562.50
Lucent Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$6,720.00 / $7,505.00 / $8,550.00
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$70.00 / $2,718.90 / $4,128.70
Providence
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,961.00 / $2,120.00 / $3,338.93
Providence
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,961.00 / $1,961.00 / $2,500.00
The Alliance
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,568.80 / $1,696.00 / $2,157.10
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,961.00 / $1,961.00 / $3,690.49