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Hawaii 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
$1,924.00 / $2,747.00 / $5,484.00
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$2,399.88 / $2,399.88 / $2,399.88
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$2,101.69 / $2,673.54 / $3,208.25
HMSA
Facility/Professional
Professional
Modifier
Low / Median / High Price
$2,839.57 / $3,190.34 / $3,709.70
Kaiser Permanente
Facility/Professional
Professional
Modifier
Low / Median / High Price
$2,352.71 / $2,566.60 / $2,994.36
United
Facility/Professional
Facility
Modifier
Low / Median / High Price
$2,912.00 / $2,912.00 / $2,912.00
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$2,181.61 / $2,673.54 / $3,458.46
University Health Alliance
Facility/Professional
Professional
Modifier
Low / Median / High Price
$29.27 / $1,940.46 / $4,162.21