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Montana rates for HCPCS Q4180

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

Insurance Carrier
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$660.69 / $660.69 / $794.33
BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$64,565.42 / $83,176.38 / $95,499.26
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$660.69 / $1,174.90 / $1,174.90
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$660.69 / $933.25 / $1,174.90
MountainHealth Co-op
Facility/Professional
Facility
Modifier
Low / Median / High Price
$177.83 / $398.11 / $1,202.26
MountainHealth Co-op
Facility/Professional
Professional
Modifier
Low / Median / High Price
$177.83 / $398.11 / $1,202.26
Providence
Facility/Professional
Facility
Modifier
Low / Median / High Price
$181.97 / $660.69 / $1,230.27
Providence
Facility/Professional
Professional
Modifier
Low / Median / High Price
$79.43 / $125.89 / $1,819.70
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$125.89 / $165.96 / $1,659.59