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Maryland rates for HCPCS 21255

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

Insurance Carrier
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,222.94 / $1,391.16 / $1,590.64
CareFirst
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,571.57 / $1,620.44 / $1,782.48
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$507.00 / $507.00 / $641.21
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,258.91 / $1,749.82 / $3,151.93
Kaiser Permanente
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,377.06 / $1,776.41 / $2,341.26
United
Facility/Professional
Facility
Modifier
Low / Median / High Price
$847.00 / $847.00 / $1,560.00
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,101.71 / $1,507.36 / $2,765.22
Wellpoint
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,322.28 / $1,583.62 / $1,968.26