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California 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
$1,992.00 / $8,050.00 / $18,309.00
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,152.65 / $1,379.00 / $7,311.69
Anthem BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$3,028.00 / $9,447.00 / $18,544.00
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,525.61 / $1,962.65 / $3,962.44
Blue Shield
Facility/Professional
Facility
Modifier
Low / Median / High Price
$64.40 / $100.00 / $7,296.75
Blue Shield
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,076.15 / $1,562.85 / $3,512.14
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$2,277.00 / $2,277.00 / $2,277.00
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,302.71 / $1,709.48 / $3,778.24
Contra Costa Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,116.90 / $1,582.47 / $2,112.75
Kaiser Permanente
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,266.69 / $1,748.88 / $3,138.04
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
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$32.34 / $32.34 / $32.34
Providence
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,390.19 / $1,759.29 / $2,534.40
Providence
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,306.45 / $1,783.69 / $3,659.43
Sutter Health Plus
Facility/Professional
Professional
Modifier
Low / Median / High Price
$4,536.76 / $4,536.76 / $4,536.76
The Alliance
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,278.66 / $1,675.35 / $2,112.75
United
Facility/Professional
Facility
Modifier
Low / Median / High Price
$5,830.00 / $12,341.00 / $26,451.00
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,100.11 / $1,444.79 / $3,087.63