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Utah rates for HCPCS 40804

Removal of embedded foreign body, vestibule of mouth; simple

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$169.82 / $3,162.28 / $4,570.88
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$109.65 / $186.21 / $416.87
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$138.04 / $223.87 / $346.74
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$32.36 / $33.11 / $416.87
Regence BlueShield
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,348.96 / $1,584.89 / $3,467.37
Regence BlueShield
Facility/Professional
Professional
Modifier
Low / Median / High Price
$165.96 / $275.42 / $446.68
Select Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$125.89 / $223.87 / $478.63
U of Utah Health Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$154.88 / $269.15 / $389.05
United
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,698.24 / $4,466.84 / $5,128.61
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$114.82 / $194.98 / $331.13