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South Dakota rates for HCPCS 21275

Secondary revision of orbitocraniofacial reconstruction

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$840.54 / $840.54 / $4,338.00
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$703.88 / $840.54 / $2,003.65
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,457.35 / $1,897.11 / $2,371.39
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,085.90 / $1,385.87 / $2,194.09
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$784.00 / $1,728.91 / $14,641.99
Midlands
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,545.35 / $2,063.13 / $8,712.51
Midlands
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,272.35 / $1,761.18 / $2,261.30
Sanford Health Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,031.45 / $1,405.54 / $1,653.48
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
$764.36 / $1,500.48 / $2,334.08
Wellmark
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,640.30 / $2,007.00 / $2,007.00