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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
$12,882.50 / $42,657.95 / $57,543.99
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$23.99 / $25.12 / $30.90
BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$30.90 / $79,432.82 / $95,499.26
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$30.90 / $30.90 / $30.90
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$30.90 / $30.90 / $43.65
MountainHealth Co-op
Facility/Professional
Facility
Modifier
Low / Median / High Price
$33.88 / $33.88 / $39.81
MountainHealth Co-op
Facility/Professional
Professional
Modifier
Low / Median / High Price
$33.88 / $33.88 / $39.81
Providence
Facility/Professional
Facility
Modifier
Low / Median / High Price
$25.70 / $38.02 / $181.97
Providence
Facility/Professional
Professional
Modifier
Low / Median / High Price
$50.12 / $79.43 / $125.89
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$30.90 / $125.89 / $125.89