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Utah rates for HCPCS Q4199

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

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$128.94 / $128.94 / $128.94
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$111.15 / $122.27 / $138.94
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$387.31 / $474.49 / $552.54
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$111.15 / $111.15 / $111.15
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$30.00 / $45.00 / $60.00
Regence BlueShield
Facility/Professional
Professional
Modifier
Low / Median / High Price
$110.04 / $122.27 / $122.27
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$111.15 / $111.15 / $111.15