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Montana rates for HCPCS 21159

Reconstruction midface, LeFort III (extra and intracranial) with forehead advancement (eg, mono bloc), requiring bone grafts (includes obtaining autografts); without LeFort I

Insurance Carrier
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$2,570.40 / $3,630.78 / $6,760.83
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$4,073.80 / $4,073.80 / $4,073.80
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$2,089.30 / $3,630.78 / $4,073.80
MountainHealth Co-op
Facility/Professional
Facility
Modifier
Low / Median / High Price
$4,168.69 / $4,466.84 / $4,786.30
MountainHealth Co-op
Facility/Professional
Professional
Modifier
Low / Median / High Price
$4,168.69 / $4,466.84 / $4,786.30
Providence
Facility/Professional
Facility
Modifier
Low / Median / High Price
$2,570.40 / $4,073.80 / $5,495.41
Providence
Facility/Professional
Professional
Modifier
Low / Median / High Price
$79.43 / $3,548.13 / $5,370.32
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$3,311.31 / $4,265.80 / $4,897.79