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Wisconsin rates for HCPCS 21195

Reconstruction of mandibular rami and/or body, sagittal split; without internal rigid fixation

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,318.26 / $2,754.23 / $14,454.40
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,202.26 / $1,348.96 / $3,715.35
Anthem BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$6,606.93 / $10,964.78 / $18,197.01
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,412.54 / $2,754.23 / $7,413.10
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$3,548.13 / $4,073.80 / $6,918.31
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,698.24 / $5,495.41 / $6,165.95
DeanCare
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,318.26 / $2,754.23 / $9,772.37
DeanCare
Facility/Professional
Professional
Modifier
Low / Median / High Price
$2,398.83 / $3,235.94 / $4,168.69
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,348.96 / $2,951.21 / $15,135.61
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,380.38 / $2,344.23 / $14,454.40
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$32.36 / $33.11 / $70.79
Quartz
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,905.46 / $2,884.03 / $4,466.84
Quartz
Facility/Professional
Facility
Modifier
Low / Median / High Price
$7,943.28 / $15,135.61 / $22,387.21
Quartz
Facility/Professional
Professional
Modifier
Low / Median / High Price
$2,398.83 / $6,760.83 / $14,454.40
Security Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$4,466.84 / $4,466.84 / $4,466.84
Security Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$4,265.80 / $7,762.47 / $8,511.38
United
Facility/Professional
Facility
Modifier
Low / Median / High Price
$7,585.78 / $12,302.69 / $16,218.10
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,348.96 / $1,995.26 / $5,754.40