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Indiana 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
$1,261.50 / $2,318.00 / $14,063.00
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,109.78 / $1,261.50 / $1,703.02
Anthem BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,852.40 / $10,338.00 / $26,304.00
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,113.81 / $1,554.70 / $2,145.48
CareSource
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,239.48 / $1,701.25 / $2,551.88
CareSource
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,215.18 / $1,458.22 / $2,187.33
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,224.83 / $1,653.05 / $2,794.92
United
Facility/Professional
Facility
Modifier
Low / Median / High Price
$4,472.00 / $10,113.00 / $15,750.00
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,139.08 / $1,479.71 / $2,657.22