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Montana rates for HCPCS Q4104

Integra bilayer matrix wound dressing (BMWD), per sq cm (add-on, list separately in addition to primary procedure)

Insurance Carrier
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$51.51 / $55.59 / $59.16
BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$64,999.99 / $81,499.99 / $94,999.99
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$56.83 / $56.83 / $122.42
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$51.00 / $56.83 / $56.83
Providence
Facility/Professional
Facility
Modifier
Low / Median / High Price
$17.46 / $51.00 / $65.50
Providence
Facility/Professional
Professional
Modifier
Low / Median / High Price
$54.02 / $55.34 / $65.50
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$51.00 / $51.00 / $51.00