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Utah rates for HCPCS Q4124

OASIS ultra tri-layer 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
$2.88 / $2.88 / $2.88
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$2.49 / $2.73 / $3.11
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$10.60 / $13.50 / $15.52
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$2.49 / $2.49 / $2.49
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$15.10 / $45.00 / $60.00
Regence BlueShield
Facility/Professional
Professional
Modifier
Low / Median / High Price
$2.46 / $2.73 / $2.73
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$2.49 / $2.49 / $2.49