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Indiana rates for HCPCS 21155

Reconstruction midface, LeFort III (extracranial), any type, requiring bone grafts (includes obtaining autografts); with LeFort I

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,386.00 / $3,290.58 / $14,063.00
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,947.20 / $2,026.01 / $2,744.38
Anthem BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$4,838.00 / $17,380.30 / $25,253.12
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,938.98 / $2,813.50 / $3,882.63
CareSource
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,947.09 / $2,531.21 / $2,920.64
CareSource
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,947.09 / $2,336.51 / $2,920.64
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$2,185.32 / $2,836.42 / $4,704.85
United
Facility/Professional
Facility
Modifier
Low / Median / High Price
$4,472.00 / $10,113.00 / $15,750.00
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,779.03 / $2,443.61 / $4,267.59