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Montana rates for HCPCS Q4256

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

Insurance Carrier
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$742.40 / $801.20 / $852.65
BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$64,999.99 / $81,499.99 / $94,999.99
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,067.33 / $1,067.33 / $1,067.33
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$735.05 / $1,067.33 / $1,067.33
Providence
Facility/Professional
Facility
Modifier
Low / Median / High Price
$735.05 / $1,067.33 / $1,207.70
Providence
Facility/Professional
Professional
Modifier
Low / Median / High Price
$797.46 / $797.46 / $1,159.40
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$735.05 / $735.05 / $735.05