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Montana rates for HCPCS Q4103

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

Insurance Carrier
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$12.62 / $13.62 / $14.49
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$14.30 / $14.30 / $14.30
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$12.49 / $14.30 / $14.30
Providence
Facility/Professional
Facility
Modifier
Low / Median / High Price
$4.67 / $12.49 / $15.60
Providence
Facility/Professional
Professional
Modifier
Low / Median / High Price
$13.55 / $13.55 / $15.78
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$12.49 / $12.49 / $12.49