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Montana rates for HCPCS 21145

Reconstruction midface, LeFort I; single piece, segment movement in any direction, requiring bone grafts (includes obtaining autografts)

Insurance Carrier
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,412.54 / $1,621.81 / $3,890.45
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$2,454.71 / $2,454.71 / $2,454.71
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,258.93 / $2,238.72 / $2,691.53
MountainHealth Co-op
Facility/Professional
Facility
Modifier
Low / Median / High Price
$2,570.40 / $2,691.53 / $2,818.38
MountainHealth Co-op
Facility/Professional
Professional
Modifier
Low / Median / High Price
$2,570.40 / $2,691.53 / $2,818.38
Providence
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,548.82 / $2,187.76 / $3,235.94
Providence
Facility/Professional
Professional
Modifier
Low / Median / High Price
$79.43 / $2,187.76 / $3,162.28
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,949.84 / $2,570.40 / $3,019.95