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Montana rates for HCPCS Q4133

Grafix PRIME, GrafixPL PRIME, Stravix and StravixPL, per sq cm (add-on, list separately in addition to primary procedure)

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$992.74 / $992.74 / $992.74
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$138.74 / $142.90 / $264.31
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
$155.66 / $155.66 / $404.30
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$138.74 / $155.66 / $155.66
Providence
Facility/Professional
Facility
Modifier
Low / Median / High Price
$138.74 / $155.66 / $280.48
Providence
Facility/Professional
Professional
Modifier
Low / Median / High Price
$147.94 / $150.52 / $176.03
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$138.74 / $138.74 / $138.74