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Montana rates for HCPCS Q4253

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

Insurance Carrier
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$76.55 / $82.61 / $87.92
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$81.61 / $81.61 / $81.61
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$75.79 / $81.61 / $81.61
Providence
Facility/Professional
Facility
Modifier
Low / Median / High Price
$75.79 / $81.61 / $149.29
Providence
Facility/Professional
Professional
Modifier
Low / Median / High Price
$77.56 / $82.23 / $173.95
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$75.79 / $75.79 / $75.79