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New Hampshire 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
$178.13 / $178.13 / $213.76
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$169.74 / $178.13 / $178.13
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$161.37 / $161.37 / $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 / $258.54
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$178.13 / $202.90 / $202.90