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West Virginia 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
$1,400.00 / $2,128.04 / $3,262.93
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$2,112.16 / $2,223.96 / $3,116.82
CareSource
Facility/Professional
Facility
Modifier
Low / Median / High Price
$2,274.37 / $2,526.90 / $2,753.10
CareSource
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,255.40 / $2,447.19 / $2,447.19
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$2,447.00 / $2,447.00 / $2,447.00
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$2,081.71 / $3,253.49 / $6,572.98
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,738.70 / $2,855.06 / $3,882.38