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Michigan rates for HCPCS 21077

Impression and custom preparation; orbital prosthesis

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$2,226.89 / $2,312.54 / $2,784.31
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,690.09 / $2,226.89 / $2,784.31
BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$3,949.24 / $3,949.24 / $3,949.24
BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$514.72 / $2,738.14 / $4,462.64
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,553.86 / $2,556.42 / $3,849.43
Health Alliance Plan
Facility/Professional
Facility
Modifier
Low / Median / High Price
$2,226.89 / $2,456.64 / $2,681.19
Health Alliance Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$2,106.48 / $2,456.64 / $3,477.50
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$206.00 / $1,450.57 / $2,465.93
United
Facility/Professional
Facility
Modifier
Low / Median / High Price
$3,500.00 / $8,702.00 / $10,652.00
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$2,109.37 / $2,791.84 / $3,742.56