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Washington rates for HCPCS Q4180

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

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$721.74 / $721.74 / $721.74
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$656.12 / $721.74 / $787.35
Asuris Northwest Health
Facility/Professional
Facility
Modifier
Low / Median / High Price
$656.12 / $1,417.80 / $2,502.00
Asuris Northwest Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$613.48 / $656.12 / $5,838.00
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$618.98 / $618.98 / $2,060.28
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$656.12 / $656.12 / $804.68
Kaiser Permanente
Facility/Professional
Facility
Modifier
Low / Median / High Price
$656.12 / $656.12 / $885.76
Kaiser Permanente
Facility/Professional
Professional
Modifier
Low / Median / High Price
$656.12 / $656.12 / $820.15
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
$393.38 / $656.12 / $1,364.73
Premera BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,384.44 / $1,384.44 / $1,417.80
Premera BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,284.35 / $1,417.80 / $1,501.20
Regence BlueShield
Facility/Professional
Facility
Modifier
Low / Median / High Price
$656.12 / $656.12 / $656.12
Regence BlueShield
Facility/Professional
Professional
Modifier
Low / Median / High Price
$623.30 / $656.12 / $656.12
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$656.12 / $656.12 / $787.34
Wellpoint
Facility/Professional
Professional
Modifier
Low / Median / High Price
$254.99 / $656.12 / $656.12