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Idaho rates for HCPCS Q4133

Grafix PRIME, GrafixPL PRIME, Stravix and StravixPL, per sq cm (add-on, list separately in addition to primary procedure)

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$136.18 / $136.18 / $136.18
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$136.18 / $152.61 / $208.11
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$130.88 / $138.74 / $138.74
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$138.74 / $138.74 / $138.74
Moda Health
Facility/Professional
Facility
Modifier
Low / Median / High Price
$136.18 / $173.43 / $221.99
Moda Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$138.74 / $145.68 / $173.43
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$104.29 / $124.88 / $265.92
Regence BlueShield
Facility/Professional
Professional
Modifier
Low / Median / High Price
$166.49 / $166.49 / $166.49
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$138.74 / $138.74 / $138.74