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Montana rates for HCPCS 15772

Grafting of autologous fat harvested by liposuction technique to trunk, breasts, scalp, arms, and/or legs; each additional 50 cc injectate, or part thereof (List separately in addition to code for primary procedure)

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,785.00 / $1,785.00 / $1,785.00
BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$47,000.00 / $81,499.99 / $94,999.99
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$231.88 / $231.88 / $231.88
Providence
Facility/Professional
Facility
Modifier
Low / Median / High Price
$115.40 / $150.07 / $231.88