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Utah rates for HCPCS Q4219

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

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,000.00 / $1,000.00 / $1,000.00
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$100.00 / $1,000.00 / $1,023.29
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,023.29 / $1,023.29 / $1,023.29
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,023.29 / $1,023.29 / $1,023.29
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
$93.33 / $117.49 / $125.89
U of Utah Health Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$131.83 / $173.78 / $213.80
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$125.89 / $134.90 / $794.33