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Utah rates for HCPCS Q4250

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

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$3,456.28 / $3,456.28 / $3,456.28
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$2,979.56 / $3,277.51 / $3,724.44
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$2,979.55 / $3,335.82 / $6,812.10
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$2,979.55 / $2,979.55 / $2,979.55
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$30.00 / $30.00 / $30.00
Regence BlueShield
Facility/Professional
Professional
Modifier
Low / Median / High Price
$2,949.76 / $3,277.51 / $3,277.51
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$2,979.56 / $2,979.56 / $2,979.56