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Louisiana 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
$209.56 / $209.56 / $209.56
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$167.65 / $209.56 / $209.56
BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$173.13 / $173.13 / $259.70
BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$173.13 / $173.13 / $176.59
Christus
Facility/Professional
Facility
Modifier
Low / Median / High Price
$121.37 / $121.37 / $121.37
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$178.13 / $178.13 / $178.13
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$178.13 / $178.13 / $178.13
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$192.79 / $202.90 / $225.62