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Utah rates for HCPCS Q4102

Oasis wound matrix, per sq cm (add-on, list separately in addition to primary procedure)

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$12.88 / $12.88 / $12.88
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$10.96 / $12.02 / $31.62
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$14.13 / $16.98 / $19.50
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$11.75 / $11.75 / $11.75
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$13.49 / $30.20 / $75.86
Regence BlueShield
Facility/Professional
Professional
Modifier
Low / Median / High Price
$15.14 / $131.83 / $162.18
Select Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$12.30 / $12.88 / $120.23
U of Utah Health Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$10.72 / $11.75 / $154.88
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$30.20 / $125.89 / $125.89