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Montana rates for HCPCS Q4102

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

Insurance Carrier
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$12.00 / $12.95 / $35.43
BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$47,000.00 / $81,499.99 / $94,999.99
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$13.71 / $13.71 / $31.88
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$11.88 / $13.71 / $13.71
Providence
Facility/Professional
Facility
Modifier
Low / Median / High Price
$4.67 / $11.88 / $16.18
Providence
Facility/Professional
Professional
Modifier
Low / Median / High Price
$12.89 / $12.89 / $15.63
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$11.88 / $11.88 / $11.88