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Montana rates for HCPCS Q4197

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

Insurance Carrier
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$70.70 / $71.40 / $77.77
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$83.94 / $83.94 / $83.94
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$70.70 / $83.94 / $83.94
Providence
Facility/Professional
Facility
Modifier
Low / Median / High Price
$70.70 / $83.94 / $119.28
Providence
Facility/Professional
Professional
Modifier
Low / Median / High Price
$76.69 / $76.69 / $119.28
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$70.70 / $70.70 / $70.70