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Tennessee 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
$1,225.00 / $2,891.00 / $7,602.00
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,207.99 / $1,401.38 / $2,139.78
BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$3,014.00 / $6,038.00 / $9,283.00
BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,341.05 / $1,809.35 / $2,862.60
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$30.00 / $30.00 / $30.00
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,402.31 / $1,916.94 / $2,882.75
Lucent Health
Facility/Professional
Facility
Modifier
Low / Median / High Price
$55.00 / $12,215.52 / $12,498.64
Lucent Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$10,981.50 / $10,981.50 / $11,109.83
United
Facility/Professional
Facility
Modifier
Low / Median / High Price
$2,905.00 / $6,073.00 / $10,287.00
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,233.63 / $1,517.22 / $2,831.27