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Utah rates for HCPCS Q4190

Artacent AC, per sq cm (add-on, list separately in addition to primary procedure)

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$128.82 / $128.82 / $128.82
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$112.20 / $112.20 / $575.44
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$208.93 / $309.03 / $426.58
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$112.20 / $112.20 / $112.20
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
$117.49 / $120.23 / $125.89
U of Utah Health Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$100.00 / $112.20 / $158.49
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$125.89 / $134.90 / $812.83