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Revitalon

Pennsylvania rates for HCPCS Q4157

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

Rates data updated July 2026.

How much does Revitalon cost?

$178

Typical negotiated rate. In Pennsylvania, July 2026.

Insurers have agreed to pay about $178 for this service. The price depends on where it is billed: about $174 from a physician practice, and about $178 from a hospital or other facility. The two figures are alternatives, not parts of one bill.

These are rates insurers have negotiated with providers, not the amount a patient is billed. What you owe depends on your plan's deductible and coinsurance. Based on rates published by 8 insurance carriers under federal price transparency rules.

Where it's billed changes the price

Billed byTypicalRange
Physician practiceA doctor's office, clinic or independent provider$174$166 to $178
FacilityA hospital or hospital-owned outpatient department$178$178 to $178

How much rates vary

Facilitymedian $178 · 10th to 90th $155 to $468Professionalmedian $174 · 10th to 90th $126 to $178
$10$100$1K$10Kfacility $178professional $174

Distribution of negotiated rates across all payers (price axis is log-scale). Each curve is scaled to its own total: facility and professional rates are different services, shown together to compare where they cluster. Need provider-level prices or 24+ months of history? Contact us.

Rates by insurance carrier

Insurance Carrier
Aetna
Setting
Facility
Modifier
Global
Typical Low
$177.83
Median
$177.83
Typical High
$177.83
Aetna
Setting
Professional
Modifier
Global
Typical Low
$165.96
Median
$177.83
Typical High
$177.83
Capital Blue Cross
Setting
Facility
Modifier
Global
Typical Low
$147.91
Median
$173.78
Typical High
$8,511.38
Capital Blue Cross
Setting
Professional
Modifier
Global
Typical Low
$173.78
Median
$173.78
Typical High
$173.78
Cigna
Setting
Facility
Modifier
Global
Typical Low
$125.89
Median
$446.68
Typical High
$478.63
Cigna
Setting
Professional
Modifier
Global
Typical Low
$125.89
Median
$125.89
Typical High
$125.89
Emblem Health
Setting
Professional
Modifier
Global
Typical Low
$151.36
Median
$177.83
Typical High
$223.87
Geisinger
Setting
Professional
Modifier
Global
Typical Low
$120.23
Median
$158.49
Typical High
$218.78
Martin's Point
Setting
Facility
Modifier
Global
Typical Low
$177.83
Median
$177.83
Typical High
$177.83
Martin's Point
Setting
Professional
Modifier
Global
Typical Low
$165.96
Median
$177.83
Typical High
$177.83
UPMC Health Plan
Setting
Facility
Modifier
Global
Typical Low
$8.32
Median
$8.32
Typical High
$8.32
UPMC Health Plan
Setting
Professional
Modifier
Global
Typical Low
$8.32
Median
$8.32
Typical High
$8.51
United
Setting
Facility
Modifier
Global
Typical Low
$154.88
Median
$154.88
Typical High
$154.88
United
Setting
Professional
Modifier
Global
Typical Low
$125.89
Median
$125.89
Typical High
$177.83

Where Pennsylvania sits

The same service costs 1.5 times more in Alaska than in Minnesota. Every bar is a state, most expensive first. Touch or drag across it to read any state, then open that state for its carriers and full range.

Pennsylvania· 7th of 51

$178

AK $209MN $138

Median negotiated rate in each state, from every insurer that publishes one. States where no insurer publishes a rate for this service are not shown.