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Montana rates for HCPCS Q4122

DermACELL, DermACELL AWM or DermACELL AWM Porous, per sq cm (add-on, list separately in addition to primary procedure)

Insurance Carrier
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$96.80 / $100.43 / $100.43
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$102.85 / $102.85 / $102.85
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$102.85 / $102.85 / $102.85
Providence
Facility/Professional
Facility
Modifier
Low / Median / High Price
$96.80 / $121.00 / $137.50
Providence
Facility/Professional
Professional
Modifier
Low / Median / High Price
$102.85 / $132.00 / $137.50
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$110.00 / $110.00 / $110.00