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Montana rates for HCPCS Q4250

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

Insurance Carrier
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$3,009.35 / $3,247.71 / $3,456.28
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$2,979.55 / $3,268.29 / $3,268.29
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$2,979.55 / $3,268.29 / $3,268.29
Providence
Facility/Professional
Facility
Modifier
Low / Median / High Price
$2,979.56 / $3,068.94 / $3,562.50
Providence
Facility/Professional
Professional
Modifier
Low / Median / High Price
$3,106.23 / $3,232.54 / $4,216.35
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$2,979.56 / $2,979.56 / $2,979.56