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Montana rates for HCPCS Q4203

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

Insurance Carrier
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,063.42 / $1,147.65 / $1,221.34
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$342.66 / $342.66 / $1,052.89
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$325.67 / $1,052.89 / $1,052.89
Providence
Facility/Professional
Facility
Modifier
Low / Median / High Price
$353.99 / $1,052.89 / $1,084.47
Providence
Facility/Professional
Professional
Modifier
Low / Median / High Price
$339.83 / $1,142.28 / $1,340.94
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,052.89 / $1,052.89 / $1,052.89