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Montana rates for HCPCS Q4101

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

Insurance Carrier
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$30.20 / $30.20 / $134.90
BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$91.20 / $64,565.42 / $95,499.26
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$34.67 / $34.67 / $89.13
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$30.20 / $34.67 / $35.48
MountainHealth Co-op
Facility/Professional
Facility
Modifier
Low / Median / High Price
$32.36 / $35.48 / $58.88
MountainHealth Co-op
Facility/Professional
Professional
Modifier
Low / Median / High Price
$32.36 / $35.48 / $58.88
Providence
Facility/Professional
Facility
Modifier
Low / Median / High Price
$30.20 / $43.65 / $173.78
Providence
Facility/Professional
Professional
Modifier
Low / Median / High Price
$34.67 / $58.88 / $125.89
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$45.71 / $125.89 / $125.89