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Ohio rates for HCPCS 21077

Impression and custom preparation; orbital prosthesis

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,685.12 / $2,715.57 / $7,776.08
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,685.12 / $2,037.80 / $3,728.06
Anthem BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$2,003.00 / $4,426.00 / $19,117.00
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,748.59 / $2,393.52 / $3,785.00
CareSource
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,559.24 / $2,476.88 / $3,126.83
CareSource
Facility/Professional
Professional
Modifier
Low / Median / High Price
$2,220.78 / $2,826.45 / $127,498.73
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$21,571.00 / $21,571.00 / $21,571.00
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,896.95 / $2,800.79 / $4,141.37
Medical Mutual of Ohio
Facility/Professional
Facility
Modifier
Low / Median / High Price
$3,013.24 / $3,013.24 / $3,013.24
Medical Mutual of Ohio
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,896.95 / $2,815.74 / $4,141.37
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$217.67 / $1,479.65 / $2,530.82
United
Facility/Professional
Facility
Modifier
Low / Median / High Price
$3,206.00 / $6,231.00 / $10,075.00
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,618.67 / $2,753.21 / $4,108.56