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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
$912.01 / $1,047.13 / $1,230.27
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$338.84 / $338.84 / $1,047.13
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$323.59 / $1,047.13 / $1,479.11
MountainHealth Co-op
Facility/Professional
Facility
Modifier
Low / Median / High Price
$234.42 / $316.23 / $407.38
MountainHealth Co-op
Facility/Professional
Professional
Modifier
Low / Median / High Price
$234.42 / $316.23 / $407.38
Providence
Facility/Professional
Facility
Modifier
Low / Median / High Price
$181.97 / $1,047.13 / $1,778.28
Providence
Facility/Professional
Professional
Modifier
Low / Median / High Price
$79.43 / $125.89 / $371.54
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$125.89 / $165.96 / $1,000.00