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Michigan 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
$1,689.19 / $4,933.00 / $4,933.00
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,203.01 / $1,689.19 / $1,754.16
BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$6,502.85 / $7,632.44 / $10,340.74
BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$352.87 / $1,896.11 / $3,330.07
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$983.15 / $1,563.90 / $2,977.92
Health Alliance Plan
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,410.03 / $1,689.19 / $6,906.00
Health Alliance Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,311.25 / $1,482.36 / $2,190.88
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$137.00 / $920.81 / $1,526.14
United
Facility/Professional
Facility
Modifier
Low / Median / High Price
$3,500.00 / $8,702.00 / $10,652.00
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,379.04 / $1,674.26 / $2,273.23