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Maine rates for HCPCS Q4180

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

Insurance Carrier
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$656.12 / $682.37 / $682.37
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$656.12 / $656.12 / $721.73
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$656.12 / $656.12 / $656.12
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$656.12 / $656.12 / $656.12
Harvard Pilgrim
Facility/Professional
Professional
Modifier
Low / Median / High Price
$656.12 / $656.12 / $656.12
Martin's Point
Facility/Professional
Professional
Modifier
Low / Median / High Price
$656.12 / $682.37 / $682.37
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$656.12 / $656.12 / $951.37