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New Hampshire rates for HCPCS 21077

Impression & Preparation Orbital Prosthesis

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$2,919.10 / $7,521.38 / $8,432.35
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,958.00 / $2,365.32 / $2,834.14
Anthem BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$4,769.10 / $5,299.00 / $8,600.00
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,717.17 / $2,823.52 / $3,988.68
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$3,013.24 / $3,013.24 / $3,013.24
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$2,451.44 / $3,872.76 / $6,368.81
Harvard Pilgrim
Facility/Professional
Professional
Modifier
Low / Median / High Price
$2,096.63 / $3,522.70 / $6,734.71
United
Facility/Professional
Facility
Modifier
Low / Median / High Price
$11,155.00 / $11,155.00 / $11,155.00
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$2,500.17 / $3,643.68 / $6,243.44
Well Sense
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,453.16 / $1,760.09 / $2,112.11