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Utah rates for HCPCS L8604

Injectable bulking agent, dextranomer/hyaluronic acid copolymer implant, urinary tract, 1 ml, includes shipping and necessary supplies

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$2,511.89 / $2,511.89 / $2,511.89
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$95.50 / $2,398.83 / $2,511.89
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
$3,090.30 / $3,090.30 / $3,548.13