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Montana rates for HCPCS 21255

Reconstruction of zygomatic arch and glenoid fossa with bone and cartilage (includes obtaining autografts)

Insurance Carrier
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,394.53 / $1,951.24 / $7,311.69
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$2,095.31 / $2,095.31 / $2,095.31
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,171.23 / $2,095.31 / $2,209.27
Providence
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,036.08 / $1,424.61 / $2,095.31
Providence
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,280.41 / $2,095.31 / $2,814.70
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,872.72 / $2,239.87 / $2,514.55