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Utah rates for HCPCS Q4203

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

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,230.27 / $1,230.27 / $1,230.27
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$275.42 / $1,047.13 / $1,230.27
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$346.74 / $426.58 / $707.95
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,047.13 / $1,047.13 / $1,047.13
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
$120.23 / $120.23 / $125.89
U of Utah Health Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$144.54 / $1,047.13 / $1,258.93
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$125.89 / $134.90 / $1,000.00