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Montana rates for HCPCS Q4259

Celera Dual Layer or Celera Dual Membrane, per sq cm (add-on, list separately in addition to primary procedure)

Insurance Carrier
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$720.64 / $777.72 / $827.66
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,113.27 / $1,113.27 / $1,113.27
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$713.50 / $1,113.27 / $1,113.27
Providence
Facility/Professional
Facility
Modifier
Low / Median / High Price
$713.50 / $1,113.27 / $1,600.93
Providence
Facility/Professional
Professional
Modifier
Low / Median / High Price
$774.08 / $774.08 / $1,548.12
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$713.50 / $713.50 / $713.50