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Rhode Island 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
$3,019.95 / $3,715.35 / $3,981.07
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,949.84 / $2,238.72 / $5,495.41
BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,905.46 / $2,187.76 / $3,890.45
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$2,454.71 / $3,548.13 / $4,466.84
United
Facility/Professional
Facility
Modifier
Low / Median / High Price
$3,235.94 / $7,413.10 / $13,182.57
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,949.84 / $2,818.38 / $4,786.30