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Utah rates for HCPCS Q4150

AlloWrap DS or dry, per sq cm (add-on, list separately in addition to primary procedure)

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$89.13 / $89.13 / $89.13
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$77.62 / $77.62 / $97.72
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$95.50 / $117.49 / $131.83
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$77.62 / $77.62 / $77.62
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$30.20 / $44.67 / $60.26
Regence BlueShield
Facility/Professional
Professional
Modifier
Low / Median / High Price
$123.03 / $144.54 / $162.18
Select Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$81.28 / $81.28 / $125.89
U of Utah Health Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$70.79 / $77.62 / $154.88
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$77.62 / $125.89 / $125.89