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PuraPly XT

Montana rates for HCPCS Q4197

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

Rates data updated July 2026.

Facilitymedian $129 · 10th–90th $83$2400%20%10th90th$129Professionalmedian $78 · 10th–90th $71$1910%50%10th90th$78$100.0$200.0$500.0

Distribution of negotiated rates across all payers (price axis is log-scale). Facility and professional rates are different services and are charted separately. Need provider-level prices? Contact us.

Insurance Carrier
Aetna
Setting
Professional
Modifier
Global
Typical Low
$70.79
Median
$77.62
Typical High
$81.28
Cigna
Setting
Facility
Modifier
Global
Typical Low
$83.18
Median
$83.18
Typical High
$144.54
Cigna
Setting
Professional
Modifier
Global
Typical Low
$83.18
Median
$125.89
Typical High
$181.97
MountainHealth Co-op
Setting
Facility
Modifier
Global
Typical Low
$128.82
Median
$141.25
Typical High
$239.88
MountainHealth Co-op
Setting
Professional
Modifier
Global
Typical Low
$128.82
Median
$141.25
Typical High
$239.88
Providence
Setting
Facility
Modifier
Global
Typical Low
$70.79
Median
$83.18
Typical High
$302.00
Providence
Setting
Professional
Modifier
Global
Typical Low
$79.43
Median
$83.18
Typical High
$173.78
United
Setting
Professional
Modifier
Global
Typical Low
$125.89
Median
$125.89
Typical High
$125.89