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Minnesota 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
$208.93 / $208.93 / $208.93
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$165.96 / $173.78 / $181.97
BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$162.18 / $245.47 / $257.04
BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$102.33 / $125.89 / $162.18
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$338.84 / $338.84 / $602.56
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$147.91 / $173.78 / $186.21
Health Partners
Facility/Professional
Facility
Modifier
Low / Median / High Price
$467.74 / $467.74 / $467.74
Health Partners
Facility/Professional
Professional
Modifier
Low / Median / High Price
$147.91 / $147.91 / $169.82
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$177.83 / $208.93 / $208.93
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$204.17 / $204.17 / $281.84
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$125.89 / $204.17 / $269.15