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Oklahoma 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
$169.74 / $169.74 / $169.74
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$169.74 / $169.74 / $171.84
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
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$57.13 / $171.84 / $209.56
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$202.90 / $202.90 / $796.33
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$202.90 / $202.90 / $227.25