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New Hampshire rates for HCPCS 21077

Impression and custom preparation; orbital prosthesis

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$7,585.78 / $7,585.78 / $8,511.38
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,819.70 / $2,398.83 / $3,801.89
Anthem BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$5,011.87 / $5,623.41 / $8,912.51
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,513.56 / $2,884.03 / $3,981.07
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$2,290.87 / $3,630.78 / $6,456.54
Harvard Pilgrim
Facility/Professional
Facility
Modifier
Low / Median / High Price
$11,220.18 / $11,220.18 / $11,220.18
Harvard Pilgrim
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,905.46 / $3,090.30 / $5,128.61
United
Facility/Professional
Facility
Modifier
Low / Median / High Price
$11,220.18 / $11,220.18 / $11,220.18
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$2,089.30 / $3,235.94 / $5,495.41
Well Sense
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,584.89 / $1,584.89 / $2,511.89