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Montana rates for HCPCS Q4111

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

Insurance Carrier
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$7.95 / $8.58 / $24.08
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$8.68 / $8.68 / $20.69
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$7.87 / $8.68 / $8.68
Providence
Facility/Professional
Facility
Modifier
Low / Median / High Price
$7.03 / $8.11 / $11.90
Providence
Facility/Professional
Professional
Modifier
Low / Median / High Price
$8.25 / $8.53 / $10.02
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$7.87 / $7.87 / $7.87