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Montana rates for HCPCS 21077

Impression & Preparation Orbital Prosthesis

Insurance Carrier
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,807.76 / $3,031.36 / $11,875.20
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$2,725.75 / $2,725.75 / $2,725.75
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,728.41 / $2,836.66 / $4,169.64
Providence
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,366.30 / $2,093.44 / $3,430.69
Providence
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,965.95 / $3,010.80 / $4,327.13
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$3,120.18 / $3,777.77 / $4,560.87