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Montana rates for HCPCS Q4124

OASIS ultra tri-layer wound matrix, per sq cm (add-on, list separately in addition to primary procedure)

Insurance Carrier
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$2.50 / $2.71 / $2.88
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$10.38 / $10.38 / $10.38
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$2.49 / $10.38 / $10.38
Providence
Facility/Professional
Facility
Modifier
Low / Median / High Price
$2.49 / $10.38 / $11.45
Providence
Facility/Professional
Professional
Modifier
Low / Median / High Price
$2.70 / $2.70 / $11.13
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$2.49 / $2.49 / $2.49