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Utah rates for HCPCS Q4126

MemoDerm, DermaSpan, TranZgraft or InteguPly, per sq cm (add-on, list separately in addition to primary procedure)

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$72.40 / $72.40 / $72.40
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$62.41 / $68.66 / $78.02
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$69.65 / $78.64 / $114.56
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$62.41 / $62.41 / $62.41
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$30.00 / $45.00 / $109.55
Regence BlueShield
Facility/Professional
Professional
Modifier
Low / Median / High Price
$61.79 / $68.66 / $68.66
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$62.41 / $62.41 / $62.41