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South Dakota rates for HCPCS 21155

Reconstruction midface, LeFort III (extracranial), any type, requiring bone grafts (includes obtaining autografts); with LeFort I

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$2,152.62 / $2,152.62 / $2,152.62
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,802.03 / $2,152.62 / $5,097.93
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$3,696.93 / $4,812.50 / $6,015.63
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$2,849.65 / $3,620.78 / $6,090.50
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$2,266.96 / $4,327.85 / $22,628.38
Midlands
Facility/Professional
Facility
Modifier
Low / Median / High Price
$3,215.86 / $5,008.03 / $6,659.53
Midlands
Facility/Professional
Professional
Modifier
Low / Median / High Price
$3,215.86 / $4,647.05 / $5,757.50
Sanford Health Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$2,647.13 / $3,672.21 / $4,186.74
United
Facility/Professional
Facility
Modifier
Low / Median / High Price
$4,500.00 / $4,500.00 / $4,500.00
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$2,266.96 / $3,842.71 / $5,977.55
Wellmark
Facility/Professional
Professional
Modifier
Low / Median / High Price
$4,153.39 / $5,081.80 / $5,081.80