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West Virginia 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
$1,286.86 / $1,400.00 / $2,300.00
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,286.86 / $1,391.16 / $2,086.35
CareSource
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,268.75 / $1,391.49 / $1,658.79
CareSource
Facility/Professional
Professional
Modifier
Low / Median / High Price
$756.54 / $1,474.48 / $1,474.48
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
$1,274.40 / $1,936.26 / $3,757.35
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,059.01 / $1,579.14 / $2,230.38