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Montana rates for HCPCS Q4196

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

Insurance Carrier
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$102.04 / $111.13 / $151.54
BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$64,999.99 / $81,499.99 / $94,999.99
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$120.38 / $120.38 / $120.38
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$101.03 / $120.38 / $120.38
Providence
Facility/Professional
Facility
Modifier
Low / Median / High Price
$101.03 / $120.38 / $131.69
Providence
Facility/Professional
Professional
Modifier
Low / Median / High Price
$109.61 / $109.61 / $132.11
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$101.03 / $101.03 / $101.03