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Utah 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
$1,949.84 / $6,025.60 / $8,709.64
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,174.90 / $1,778.28 / $7,413.10
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,122.02 / $1,819.70 / $2,884.03
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$32.36 / $33.11 / $2,691.53
Regence BlueShield
Facility/Professional
Facility
Modifier
Low / Median / High Price
$8,317.64 / $9,772.37 / $22,387.21
Regence BlueShield
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,737.80 / $2,630.27 / $3,467.37
Select Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,202.26 / $2,398.83 / $3,235.94
U of Utah Health Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,412.54 / $2,137.96 / $3,090.30
United
Facility/Professional
Facility
Modifier
Low / Median / High Price
$2,884.03 / $5,128.61 / $13,803.84
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,148.15 / $1,445.44 / $2,238.72