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South Dakota rates for HCPCS 21422

Open treatment of palatal or maxillary fracture (LeFort I type);

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$630.96 / $4,897.79 / $6,165.95
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$575.44 / $660.69 / $1,348.96
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,096.48 / $1,479.11 / $1,862.09
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$831.76 / $1,071.52 / $1,778.28
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$588.84 / $1,148.15 / $5,623.41
Midlands
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,318.26 / $1,513.56 / $1,513.56
Midlands
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,318.26 / $1,318.26 / $1,513.56
Sanford Health Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$758.58 / $1,096.48 / $1,230.27
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
$741.31 / $1,148.15 / $1,862.09
Wellmark
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,230.27 / $1,445.44 / $1,513.56