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Maine rates for HCPCS 21154

Reconstruction midface, LeFort III (extracranial), any type, requiring bone grafts (includes obtaining autografts); without LeFort I

Insurance Carrier
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,778.28 / $2,290.87 / $5,128.61
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,659.59 / $2,818.38 / $4,365.16
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$2,187.76 / $2,884.03 / $4,365.16
Harvard Pilgrim
Facility/Professional
Professional
Modifier
Low / Median / High Price
$2,089.30 / $2,570.40 / $4,677.35
Martin's Point
Facility/Professional
Professional
Modifier
Low / Median / High Price
$2,041.74 / $2,754.23 / $5,754.40
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,778.28 / $2,570.40 / $3,890.45