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Utah rates for HCPCS Q4110

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

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$75.86 / $75.86 / $75.86
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$64.57 / $66.07 / $117.49
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$66.07 / $93.33 / $100.00
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$66.07 / $66.07 / $66.07
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$30.20 / $51.29 / $75.86
Regence BlueShield
Facility/Professional
Professional
Modifier
Low / Median / High Price
$67.61 / $131.83 / $162.18
Select Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$44.67 / $67.61 / $120.23
U of Utah Health Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$58.88 / $66.07 / $144.54
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$79.43 / $125.89 / $125.89