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Montana rates for HCPCS Q4116

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

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$12,982.61 / $42,318.00 / $58,104.80
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$24.89 / $25.82 / $25.82
BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$64,999.99 / $79,999.99 / $94,999.99
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$31.11 / $31.11 / $31.11
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$31.11 / $31.11 / $35.51
Providence
Facility/Professional
Facility
Modifier
Low / Median / High Price
$31.11 / $31.11 / $32.74
Providence
Facility/Professional
Professional
Modifier
Low / Median / High Price
$31.11 / $33.75 / $2,250,000.00
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$31.11 / $31.11 / $31.11