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Utah rates for HCPCS Q4122

DermACELL, DermACELL AWM or DermACELL AWM Porous, per sq cm (add-on, list separately in addition to primary procedure)

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$100.43 / $100.43 / $100.43
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$98.01 / $100.43 / $104.06
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$102.85 / $102.85 / $102.85
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$102.85 / $102.85 / $102.85
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$30.00 / $45.00 / $60.00
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$110.00 / $110.00 / $110.00