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Utah rates for HCPCS 21100

Application of halo type appliance for maxillofacial fixation, includes removal (separate procedure)

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$891.25 / $3,388.44 / $4,897.79
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$331.13 / $645.65 / $2,290.87
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$363.08 / $724.44 / $1,348.96
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$32.36 / $33.11 / $954.99
Regence BlueShield
Facility/Professional
Facility
Modifier
Low / Median / High Price
$8,317.64 / $10,000.00 / $22,387.21
Regence BlueShield
Facility/Professional
Professional
Modifier
Low / Median / High Price
$478.63 / $891.25 / $1,698.24
Select Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$416.87 / $691.83 / $1,318.26
U of Utah Health Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$478.63 / $851.14 / $1,348.96
United
Facility/Professional
Facility
Modifier
Low / Median / High Price
$2,884.03 / $5,128.61 / $13,803.84
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$331.13 / $588.84 / $1,047.13