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Montana rates for HCPCS Q4115

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

Insurance Carrier
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$12.99 / $14.02 / $14.92
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$14.13 / $14.13 / $65.95
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$12.86 / $14.13 / $14.13
Providence
Facility/Professional
Facility
Modifier
Low / Median / High Price
$11.39 / $13.25 / $33.47
Providence
Facility/Professional
Professional
Modifier
Low / Median / High Price
$13.43 / $13.95 / $18.20
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$12.86 / $12.86 / $12.86