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Utah rates for HCPCS A2005

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

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$134.90 / $134.90 / $134.90
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$134.90 / $204.17 / $263.03
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$223.87 / $223.87 / $223.87
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$218.78 / $218.78 / $223.87
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$30.20 / $44.67 / $60.26
Select Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$120.23 / $120.23 / $125.89
U of Utah Health Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$131.83 / $173.78 / $213.80
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$125.89 / $125.89 / $125.89