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South Dakota rates for HCPCS 21401

Closed treatment of fracture of orbit, except blowout; with manipulation

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$331.13 / $524.81 / $4,365.16
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$302.00 / $478.63 / $812.83
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$645.65 / $977.24 / $1,513.56
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$436.52 / $724.44 / $1,174.90
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$457.09 / $977.24 / $3,801.89
Midlands
Facility/Professional
Professional
Modifier
Low / Median / High Price
$707.95 / $724.44 / $1,174.90
Midlands
Facility/Professional
Professional
Modifier
Low / Median / High Price
$616.60 / $676.08 / $1,096.48
Sanford Health Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$501.19 / $724.44 / $1,000.00
United
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,995.26 / $1,995.26 / $1,995.26
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$389.05 / $724.44 / $1,380.38
Wellmark
Facility/Professional
Professional
Modifier
Low / Median / High Price
$645.65 / $794.33 / $1,202.26