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Nebraska 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
$4,241.22 / $10,431.19 / $20,928.72
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,992.76 / $1,992.76 / $11,334.70
BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$9,086.90 / $11,951.75 / $23,118.55
BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,912.88 / $3,260.57 / $4,347.43
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$3,766.00 / $4,812.50 / $6,550.16
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,992.76 / $3,487.33 / $7,441.00
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$2,660.10 / $4,399.39 / $6,246.50
Midlands
Facility/Professional
Facility
Modifier
Low / Median / High Price
$2,481.38 / $4,953.75 / $6,659.53
Midlands
Facility/Professional
Professional
Modifier
Low / Median / High Price
$3,708.68 / $4,710.31 / $6,550.16
United
Facility/Professional
Facility
Modifier
Low / Median / High Price
$6,178.00 / $7,441.00 / $8,816.00
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$2,660.10 / $4,542.63 / $5,729.44