Revitalon skin substitute, per square centimeter

Hospitals report these codes with terse, inconsistent chargemaster text. This plain-English title was written by an AI model from that text and has not been reviewed by a person, so it can be wrong. The prices on this page come straight from hospital filings and do not depend on it.

Model: claude-haiku-5-5
Provider: anthropic
API: message_batches
Reasoning effort: low
Max output tokens: 4096
Prompt version (hash): 444523875572
Generated: October 20, 2026

Original text from hospital filings

Revitalon 1 square cm

Payers reporting HCPCS Q4157

Payer pricing summary

Low

$51

Average

$199

Median

$169

High

$815

Payer rate distribution

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#
1	UnitedHealthcare fee schedule · outpatient · +11 other terms	415	$210	$270	$163	60%	—	$48 – $1.3k
2	Aetna fee schedule · outpatient · +12 other terms	217	$146	$202	$186	92%	—	$69 – $1.8k
3	Cigna fee schedule · outpatient · +9 other terms	217	$289	$489	$393	80%	—	$119 – $1.5k
4	Blue Cross Blue Shield fee schedule · outpatient · +8 other terms	105	$160	$176	$100	57%	—	$1 – $612
5	Humana fee schedule · outpatient · +8 other terms	96	$127	$170	$129	76%	—	$48 – $676
6	Molina fee schedule · outpatient · +6 other terms	55	$192	$251	$386	154%	—	$51 – $3.4k
7	Anthem facility · fee schedule · outpatient · +4 other terms	51	$160	$188	$163	87%	—	$0 – $1.2k
8	WellCare fee schedule · outpatient · +5 other terms	46	$136	$139	$14	10%	—	$115 – $171
9	Kaiser fee schedule · outpatient · +4 other terms	39	$207	$268	$186	69%	—	$125 – $1000
10	Ambetter fee schedule · outpatient · +3 other terms	34	$234	$245	$45	18%	—	$162 – $351
11	Devoted fee schedule · outpatient · +3 other terms	33	$125	$125	$7	6%	—	$116 – $136
12	Optum fee schedule · outpatient · +1 other terms	32	$125	$173	$91	53%	—	$113 – $459
13	Caresource fee schedule · outpatient · +2 other terms	24	$100	$94	$65	69%	—	$48 – $213
14	Oscar facility · fee schedule · outpatient · +4 other terms	19	$182	$196	$25	13%	—	$175 – $234
15	Medicare fee schedule · outpatient · +1 other terms	18	$125	$125	—	—	—	$125 – $125
16	Highmark fee schedule · outpatient · +4 other terms	16	$196	$241	$323	134%	—	$127 – $3.4k
17	Medical Mutual facility · fee schedule · outpatient · +2 other terms	14	$118	$150	$96	64%	—	$64 – $468
18	Wellmark fee schedule · both · +2 other terms	13	$173	$172	$10	6%	—	$112 – $173
19	Bcbs Nj fee schedule · outpatient	12	$163	$163	$6	4%	—	$160 – $174
20	Tricare fee schedule · outpatient · +1 other terms	11	$113	$118	$10	8%	—	$113 – $148
21	Medica fee schedule · outpatient · +4 other terms	10	$412	$415	$104	25%	—	$250 – $532
22	Regence fee schedule · outpatient · +4 other terms	10	$146	$146	$4	3%	—	$140 – $156
23	Clover facility · fee schedule · outpatient · +1 other terms	8	$123	$123	$6	5%	—	$117 – $134
24	Aetna Better Health fee schedule · inpatient · +2 other terms	7	$173	$173	—	—	—	$173 – $173
25	Bcbs La fee schedule · outpatient · +1 other terms	6	$173	$173	—	—	—	$173 – $173

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