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Hawaii rates for HCPCS 21077

Impression and custom preparation; orbital prosthesis

Insurance Carrier
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$2,154.19 / $2,154.19 / $2,422.00
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$2,228.21 / $2,730.65 / $3,276.78
HMSA
Facility/Professional
Professional
Modifier
Low / Median / High Price
$2,664.84 / $2,996.45 / $3,370.23
Kaiser Permanente
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,915.65 / $2,402.96 / $2,730.65
United
Facility/Professional
Facility
Modifier
Low / Median / High Price
$2,912.00 / $2,912.00 / $2,912.00
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$2,228.21 / $2,730.65 / $3,635.66
University Health Alliance
Facility/Professional
Professional
Modifier
Low / Median / High Price
$360.07 / $2,127.17 / $2,880.58