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Missouri 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 / $218.78
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$165.96 / $169.82 / $177.83
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$97.72 / $109.65 / $138.04
BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$123.03 / $144.54 / $194.98
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
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$165.96 / $208.93 / $467.74
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$181.97 / $204.17 / $794.33
United
Facility/Professional
Facility
Modifier
Low / Median / High Price
$269.15 / $269.15 / $316.23
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$125.89 / $190.55 / $204.17