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Utah rates for HCPCS Q2004

Irrigation solution for treatment of bladder calculi, for example renacidin, per 500 ml

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$100.00 / $100.00 / $100.00
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$97.72 / $100.00 / $120.23
Select Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$95.50 / $112.20 / $114.82
U of Utah Health Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$6.31 / $6.61 / $7.76
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$102.33 / $102.33 / $102.33