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Utah 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
$160.94 / $160.94 / $2,315.10
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$138.74 / $160.94 / $457.94
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$158.88 / $183.26 / $210.75
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$138.74 / $138.74 / $138.74
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$60.00 / $107.53 / $180.23
Regence BlueShield
Facility/Professional
Professional
Modifier
Low / Median / High Price
$137.35 / $152.61 / $189.20
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$138.74 / $138.74 / $138.74