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Maine 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
$1,230.27 / $1,548.82 / $3,630.78
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,230.27 / $1,949.84 / $2,951.21
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,513.56 / $1,949.84 / $3,019.95
Harvard Pilgrim
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,513.56 / $1,819.70 / $3,388.44
Martin's Point
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,348.96 / $1,905.46 / $4,073.80
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,202.26 / $1,778.28 / $2,691.53