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Montana rates for HCPCS Q4121

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

Insurance Carrier
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$53.28 / $57.50 / $135.85
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$59.12 / $59.12 / $121.88
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$52.75 / $59.12 / $59.12
Providence
Facility/Professional
Facility
Modifier
Low / Median / High Price
$52.75 / $59.12 / $84.55
Providence
Facility/Professional
Professional
Modifier
Low / Median / High Price
$56.19 / $57.24 / $61.09
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$52.75 / $52.75 / $52.75