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Montana rates for HCPCS Q4248

Dermacyte Amniotic Membrane Allograft, per sq cm (add-on, list separately in addition to primary procedure)

Insurance Carrier
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$549.54 / $549.54 / $691.83
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$549.54 / $3,162.28 / $3,162.28
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$549.54 / $794.33 / $3,162.28
MountainHealth Co-op
Facility/Professional
Facility
Modifier
Low / Median / High Price
$141.25 / $1,148.15 / $2,089.30
MountainHealth Co-op
Facility/Professional
Professional
Modifier
Low / Median / High Price
$141.25 / $1,148.15 / $2,089.30
Providence
Facility/Professional
Facility
Modifier
Low / Median / High Price
$181.97 / $616.60 / $3,162.28
Providence
Facility/Professional
Professional
Modifier
Low / Median / High Price
$79.43 / $125.89 / $3,162.28
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$125.89 / $165.96 / $2,691.53