go back

South Dakota rates for HCPCS 21159

Reconstruction midface, LeFort III (extra and intracranial) with forehead advancement (eg, mono bloc), requiring bone grafts (includes obtaining autografts); without LeFort I

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$2,570.40 / $2,570.40 / $4,365.16
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$2,344.23 / $2,570.40 / $5,370.32
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$4,466.84 / $5,888.44 / $7,413.10
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$3,388.44 / $4,365.16 / $6,606.93
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$2,398.83 / $4,365.16 / $27,542.29
Midlands
Facility/Professional
Professional
Modifier
Low / Median / High Price
$5,248.07 / $6,025.60 / $6,025.60
Midlands
Facility/Professional
Professional
Modifier
Low / Median / High Price
$5,248.07 / $5,248.07 / $5,754.40
Sanford Health Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$3,019.95 / $4,265.80 / $5,011.87
United
Facility/Professional
Facility
Modifier
Low / Median / High Price
$4,466.84 / $4,466.84 / $4,466.84
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$2,818.38 / $4,570.88 / $7,244.36
Wellmark
Facility/Professional
Professional
Modifier
Low / Median / High Price
$5,011.87 / $5,888.44 / $6,025.60