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Montana rates for HCPCS Q4199

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

Insurance Carrier
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$112.26 / $121.16 / $128.94
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$379.47 / $379.47 / $379.47
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$111.15 / $379.47 / $379.47
Providence
Facility/Professional
Facility
Modifier
Low / Median / High Price
$111.15 / $379.47 / $440.31
Providence
Facility/Professional
Professional
Modifier
Low / Median / High Price
$120.59 / $120.59 / $440.31
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$111.15 / $111.15 / $111.15