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Alaska rates for HCPCS 21255

Reconstruction of zygomatic arch and glenoid fossa with bone and cartilage (includes obtaining autografts)

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$3,877.32 / $9,774.00 / $14,552.94
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,242.67 / $6,576.07 / $6,576.07
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$3,372.27 / $4,529.75 / $5,764.40
Moda Health
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,245.27 / $6,576.07 / $9,206.50
Moda Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$3,241.13 / $3,889.35 / $7,895.76
Premera BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$5,010.00 / $6,757.88 / $8,200.00
Providence
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,245.27 / $6,576.07 / $9,206.50
Providence
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,992.79 / $6,591.75 / $9,020.00
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$3,432.47 / $6,210.94 / $7,972.36