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Washington rates for HCPCS 21490

Open Treatment Temporomandibular Dislocation

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,450.06 / $5,128.00 / $20,680.40
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$793.34 / $1,007.31 / $2,621.92
Asuris Northwest Health
Facility/Professional
Facility
Modifier
Low / Median / High Price
$5,096.00 / $9,124.02 / $20,178.18
Asuris Northwest Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,140.58 / $1,840.85 / $6,693.38
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$714.97 / $870.49 / $3,302.92
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$917.11 / $1,555.97 / $2,395.96
Kaiser Permanente
Facility/Professional
Facility
Modifier
Low / Median / High Price
$991.80 / $1,887.23 / $3,021.20
Kaiser Permanente
Facility/Professional
Professional
Modifier
Low / Median / High Price
$892.85 / $1,836.51 / $2,543.36
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$78.79 / $471.42 / $1,576.48
Pacific Source
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,282.96 / $1,576.84 / $1,774.16
Premera BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$803.50 / $1,043.71 / $2,412.73
Premera BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,200.75 / $1,714.99 / $2,139.85
Regence BlueShield
Facility/Professional
Facility
Modifier
Low / Median / High Price
$6,812.14 / $9,118.81 / $17,453.22
Regence BlueShield
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,064.45 / $1,534.48 / $2,056.56
United
Facility/Professional
Facility
Modifier
Low / Median / High Price
$2,912.00 / $4,016.00 / $16,315.00
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$998.34 / $1,371.12 / $2,349.08
Wellpoint
Facility/Professional
Professional
Modifier
Low / Median / High Price
$665.88 / $665.88 / $862.86