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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
$3,715.35 / $8,912.51 / $22,387.21
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,230.27 / $1,513.56 / $7,413.10
Anthem BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$6,456.54 / $11,481.54 / $17,782.79
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,513.56 / $2,041.74 / $4,168.69
Blue Shield
Facility/Professional
Facility
Modifier
Low / Median / High Price
$63.10 / $100.00 / $8,128.31
Blue Shield
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,380.38 / $1,995.26 / $3,801.89
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,288.25 / $1,737.80 / $3,548.13
Contra Costa Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,122.02 / $1,445.44 / $1,949.84
Kaiser Permanente
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,148.15 / $1,513.56 / $2,754.23
Lucent Health
Facility/Professional
Facility
Modifier
Low / Median / High Price
$54.95 / $56.23 / $12,302.69
Lucent Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$10,964.78 / $11,220.18 / $11,220.18
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,905.46 / $1,905.46 / $1,905.46
Providence
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,318.26 / $1,737.80 / $2,754.23
Providence
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,258.93 / $1,778.28 / $3,548.13
Sutter Health Plus
Facility/Professional
Professional
Modifier
Low / Median / High Price
$4,570.88 / $4,570.88 / $4,570.88
The Alliance
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,174.90 / $1,621.81 / $2,398.83
United
Facility/Professional
Facility
Modifier
Low / Median / High Price
$6,760.83 / $12,302.69 / $25,703.96
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,071.52 / $1,445.44 / $3,090.30