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Montana rates for HCPCS Q4221

Amnio Wrap2, per sq cm (add-on, list separately in addition to primary procedure)

Insurance Carrier
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,980.61 / $2,137.48 / $2,274.76
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$2,299.00 / $2,299.00 / $2,299.00
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,961.00 / $2,299.00 / $2,299.00
Providence
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,961.00 / $2,299.00 / $2,500.00
Providence
Facility/Professional
Professional
Modifier
Low / Median / High Price
$2,127.50 / $2,127.50 / $2,775.00
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,961.00 / $1,961.00 / $1,961.00