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Utah rates for HCPCS Q4103

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

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$14.13 / $14.13 / $14.13
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$12.02 / $12.02 / $31.62
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$14.45 / $17.78 / $19.05
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$12.59 / $12.59 / $12.59
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1.91 / $30.20 / $75.86
Regence BlueShield
Facility/Professional
Professional
Modifier
Low / Median / High Price
$123.03 / $144.54 / $162.18
Select Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$12.88 / $13.18 / $125.89
U of Utah Health Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$11.22 / $12.59 / $154.88
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$12.59 / $125.89 / $125.89