go back

South Dakota 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
$1,348.96 / $1,348.96 / $4,365.16
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,202.26 / $1,348.96 / $2,754.23
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$2,344.23 / $3,162.28 / $3,890.45
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,621.81 / $2,238.72 / $3,467.37
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,258.93 / $2,344.23 / $10,964.78
Midlands
Facility/Professional
Professional
Modifier
Low / Median / High Price
$2,818.38 / $3,235.94 / $3,235.94
Midlands
Facility/Professional
Professional
Modifier
Low / Median / High Price
$2,818.38 / $2,818.38 / $3,090.30
Sanford Health Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,584.89 / $2,187.76 / $2,570.40
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
$1,513.56 / $2,454.71 / $3,890.45
Wellmark
Facility/Professional
Professional
Modifier
Low / Median / High Price
$2,570.40 / $3,019.95 / $3,162.28