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Maine rates for HCPCS Q4157

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

Insurance Carrier
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$171.84 / $178.13 / $178.13
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$161.37 / $167.65 / $167.65
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
Harvard Pilgrim
Facility/Professional
Professional
Modifier
Low / Median / High Price
$178.13 / $178.13 / $178.13
Martin's Point
Facility/Professional
Professional
Modifier
Low / Median / High Price
$178.13 / $178.13 / $178.13
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$178.13 / $202.90 / $294.20