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South Dakota rates for HCPCS 21175

Reconstruction, bifrontal, superior-lateral orbital rims and lower forehead, advancement or alteration (eg, plagiocephaly, trigonocephaly, brachycephaly), with or without grafts (includes obtaining autografts)

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$2,178.83 / $2,178.83 / $4,338.00
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,821.39 / $2,178.83 / $3,969.60
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$3,793.45 / $4,892.75 / $6,115.94
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$2,872.70 / $3,619.15 / $5,749.40
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$2,026.04 / $4,413.97 / $19,652.56
Midlands
Facility/Professional
Facility
Modifier
Low / Median / High Price
$3,268.50 / $4,988.95 / $6,829.52
Midlands
Facility/Professional
Professional
Modifier
Low / Median / High Price
$3,268.50 / $4,489.16 / $5,926.89
Sanford Health Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$2,622.31 / $3,769.24 / $4,297.35
United
Facility/Professional
Facility
Modifier
Low / Median / High Price
$4,500.00 / $4,500.00 / $11,831.32
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,987.51 / $4,203.78 / $6,129.23
Wellmark
Facility/Professional
Professional
Modifier
Low / Median / High Price
$4,263.10 / $5,216.10 / $5,216.10