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Montana rates for HCPCS Q4190

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

Insurance Carrier
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$112.20 / $112.20 / $141.25
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$112.20 / $204.17 / $204.17
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$112.20 / $158.49 / $204.17
MountainHealth Co-op
Facility/Professional
Facility
Modifier
Low / Median / High Price
$338.84 / $338.84 / $870.96
MountainHealth Co-op
Facility/Professional
Professional
Modifier
Low / Median / High Price
$338.84 / $338.84 / $870.96
Providence
Facility/Professional
Facility
Modifier
Low / Median / High Price
$112.20 / $181.97 / $457.09
Providence
Facility/Professional
Professional
Modifier
Low / Median / High Price
$79.43 / $125.89 / $309.03
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$125.89 / $165.96 / $812.83