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GRAFTJACKET

Montana rates for HCPCS Q4107

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

Rates data updated July 2026.

Facilitymedian $123 · 10th–90th $93$1620%20%10th90th$123Professionalmedian $85 · 10th–90th $81$1260%50%10th90th$85$100.0$200.0$500.0

Distribution of negotiated rates across all payers (price axis is log-scale). Facility and professional rates are different services and are charted separately. Need provider-level prices? Contact us.

Insurance Carrier
Aetna
Setting
Professional
Modifier
Global
Typical Low
$81.28
Median
$83.18
Typical High
$85.11
Cigna
Setting
Facility
Modifier
Global
Typical Low
$114.82
Median
$131.83
Typical High
$251.19
Cigna
Setting
Professional
Modifier
Global
Typical Low
$100.00
Median
$125.89
Typical High
$125.89
MountainHealth Co-op
Setting
Facility
Modifier
Global
Typical Low
$104.71
Median
$123.03
Typical High
$128.82
MountainHealth Co-op
Setting
Professional
Modifier
Global
Typical Low
$104.71
Median
$123.03
Typical High
$128.82
Providence
Setting
Facility
Modifier
Global
Typical Low
$85.11
Median
$117.49
Typical High
$204.17
Providence
Setting
Professional
Modifier
Global
Typical Low
$79.43
Median
$114.82
Typical High
$158.49
United
Setting
Professional
Modifier
Global
Typical Low
$125.89
Median
$125.89
Typical High
$125.89