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Utah rates for HCPCS Q4107

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

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$83.94 / $83.94 / $5,133.00
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$81.92 / $83.94 / $86.97
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$85.96 / $85.96 / $85.96
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$85.96 / $85.96 / $85.96
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$60.00 / $121.44 / $132.74
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$136.47 / $136.47 / $136.47