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Montana rates for HCPCS Q4142

XCM biologic tissue matrix, per sq cm (add-on, list separately in addition to primary procedure)

Insurance Carrier
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$100.00 / $125.89 / $154.88
Providence
Facility/Professional
Facility
Modifier
Low / Median / High Price
$87.10 / $151.36 / $257.04
Providence
Facility/Professional
Professional
Modifier
Low / Median / High Price
$79.43 / $79.43 / $125.89
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$125.89 / $125.89 / $125.89