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Washington 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 / $178.13
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$167.65 / $178.13 / $178.13
Asuris Northwest Health
Facility/Professional
Facility
Modifier
Low / Median / High Price
$173.93 / $209.56 / $785.85
Asuris Northwest Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$163.51 / $796.33 / $943.02
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$178.13 / $178.13 / $712.52
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$178.13 / $178.13 / $178.13
Kaiser Permanente
Facility/Professional
Professional
Modifier
Low / Median / High Price
$12.82 / $12.82 / $12.82
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$50.00 / $50.00 / $75.00
Pacific Source
Facility/Professional
Facility
Modifier
Low / Median / High Price
$79,999.20 / $79,999.20 / $79,999.20
Premera BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$173.93 / $173.93 / $178.13
Premera BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$161.36 / $178.13 / $188.60
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$202.90 / $202.90 / $243.48
Wellpoint
Facility/Professional
Professional
Modifier
Low / Median / High Price
$155.08 / $155.08 / $155.08