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Montana rates for HCPCS 21490

Open treatment of temporomandibular dislocation

Insurance Carrier
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$794.33 / $1,122.02 / $2,089.30
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,230.27 / $1,230.27 / $1,230.27
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$776.25 / $1,174.90 / $1,548.82
MountainHealth Co-op
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,348.96 / $1,380.38 / $1,819.70
MountainHealth Co-op
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,348.96 / $1,380.38 / $1,819.70
Providence
Facility/Professional
Facility
Modifier
Low / Median / High Price
$794.33 / $1,318.26 / $1,819.70
Providence
Facility/Professional
Professional
Modifier
Low / Median / High Price
$79.43 / $1,122.02 / $1,621.81
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,000.00 / $1,412.54 / $1,584.89