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Texas 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
$1,086.00 / $3,620.00 / $12,480.00
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,207.99 / $1,379.67 / $2,223.98
BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,402.89 / $2,375.03 / $7,328.02
BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,195.30 / $1,489.34 / $2,055.03
Christus
Facility/Professional
Facility
Modifier
Low / Median / High Price
$80.00 / $1,191.11 / $1,200.00
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,490.92 / $1,490.92 / $1,490.92
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,331.73 / $1,819.56 / $2,828.98
Lucent Health
Facility/Professional
Facility
Modifier
Low / Median / High Price
$55.00 / $55.00 / $12,215.52
Lucent Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$10,981.50 / $10,981.50 / $11,109.83
Moda Health
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,260.67 / $1,660.71 / $2,743.42
Moda Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,620.56 / $1,944.68 / $2,411.40
Oscar Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,444.20 / $1,444.20 / $1,444.20
Providence
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,274.55 / $1,684.48 / $2,804.28
Providence
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,336.14 / $1,880.17 / $2,883.06
United
Facility/Professional
Facility
Modifier
Low / Median / High Price
$2,093.00 / $6,000.00 / $13,134.00
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,106.99 / $1,471.84 / $2,303.50
Wellpoint
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,106.48 / $1,257.31 / $1,754.95