go back

GRAFTJACKET

Montana rates for HCPCS Q4107

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

Rates data updated October 2026.

How much does GRAFTJACKET cost?

$115

Typical negotiated rate. In Montana, October 2026.

Insurers have agreed to pay about $115 for this service. The price depends on where it is billed: about $115 from a physician practice, and about $166 from a hospital or other facility.

These are rates insurers have negotiated with providers, not the amount a patient is billed. What you owe depends on your plan's deductible and coinsurance. Based on rates published by 5 insurance carriers under federal price transparency rules.

Prices by location type

Billed byTypicalRange
Physician practiceA doctor's office, clinic or independent provider$115$79.43 to $117
FacilityA hospital or hospital-owned outpatient department$166$129 to $219

How much rates vary

Facilitymedian $166 · 10th to 90th $115 to $251Professionalmedian $115 · 10th to 90th $76 to $126
$100$200$500facility $166professional $115

Distribution of negotiated rates across all payers (price axis is log-scale). Need provider-level prices or 24+ months of history? Contact us.

Rates by insurance carrier

Insurance Carrier
Aetna
Setting
Professional
Modifier
None
Typical Low
$81.28
Median
$83.18
Typical High
$87.10
Cigna
Setting
Facility
Modifier
None
Typical Low
$114.82
Median
$162.18
Typical High
$309.03
Cigna
Setting
Professional
Modifier
None
Typical Low
$114.82
Median
$114.82
Typical High
$114.82
MountainHealth Co-op
Setting
Facility
Modifier
None
Typical Low
$125.89
Median
$173.78
Typical High
$234.42
MountainHealth Co-op
Setting
Professional
Modifier
None
Typical Low
$125.89
Median
$158.49
Typical High
$234.42
Providence
Setting
Facility
Modifier
None
Typical Low
$114.82
Median
$162.18
Typical High
$309.03
Providence
Setting
Professional
Modifier
None
Typical Low
$70.79
Median
$100.00
Typical High
$117.49
United
Setting
Professional
Modifier
None
Typical Low
$125.89
Median
$125.89
Typical High
$125.89

Where Montana sits

The same service costs 1.8 times more in North Dakota than in Virginia. Every bar is a state, most expensive first. Touch or drag across it to read any state, then open that state for its carriers and full range.

Montana· 33rd of 51

$115

ND $151VA $85.11

Median negotiated rate in each state, from every insurer that publishes one. States where no insurer publishes a rate for this service are not shown.