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Ohio 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
$2,292.00 / $7,122.54 / $11,627.00
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,818.50 / $2,128.04 / $4,180.06
Anthem BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$4,142.00 / $14,428.74 / $24,745.60
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,884.43 / $2,633.16 / $4,158.34
CareSource
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,896.77 / $2,069.21 / $3,013.04
CareSource
Facility/Professional
Professional
Modifier
Low / Median / High Price
$2,231.48 / $2,231.48 / $2,840.08
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$21,571.00 / $21,571.00 / $21,571.00
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$2,103.90 / $2,955.31 / $4,281.14
Medical Mutual of Ohio
Facility/Professional
Facility
Modifier
Low / Median / High Price
$2,447.00 / $2,447.00 / $2,447.00
Medical Mutual of Ohio
Facility/Professional
Professional
Modifier
Low / Median / High Price
$2,130.06 / $3,017.83 / $4,251.89
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$253.07 / $1,495.29 / $2,508.60
United
Facility/Professional
Facility
Modifier
Low / Median / High Price
$3,206.00 / $6,231.00 / $10,075.00
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,749.10 / $2,745.75 / $4,353.16