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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
$2,729.99 / $3,613.25 / $13,574.40
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$4,072.85 / $4,072.85 / $4,072.85
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$2,088.53 / $4,037.33 / $4,072.85
Providence
Facility/Professional
Facility
Modifier
Low / Median / High Price
$2,002.96 / $2,754.07 / $4,144.05
Providence
Facility/Professional
Professional
Modifier
Low / Median / High Price
$2,475.42 / $4,037.33 / $5,356.40
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$3,541.48 / $4,251.62 / $5,727.00