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Montana rates for HCPCS Q4107

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

Insurance Carrier
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$80.90 / $83.94 / $83.94
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$114.62 / $127.79 / $251.75
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$85.96 / $100.45 / $114.62
Providence
Facility/Professional
Facility
Modifier
Low / Median / High Price
$92.59 / $96.15 / $160.72
Providence
Facility/Professional
Professional
Modifier
Low / Median / High Price
$76.41 / $114.62 / $138.53
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$136.47 / $136.47 / $136.47