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Texas rates for HCPCS 21077

Impression and custom preparation; orbital prosthesis

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,459.43 / $1,935.46 / $2,763.60
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,649.24 / $2,105.73 / $3,394.46
BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$891.59 / $1,575.15 / $4,453.50
BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,883.17 / $2,346.40 / $3,237.63
Christus
Facility/Professional
Facility
Modifier
Low / Median / High Price
$80.00 / $1,507.87 / $1,535.45
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
$1,934.66 / $2,820.89 / $4,439.60
Lucent Health
Facility/Professional
Facility
Modifier
Low / Median / High Price
$55.00 / $55.00 / $8,663.57
Lucent Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$12,931.36 / $15,775.28 / $17,883.00
Moda Health
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,785.26 / $2,772.25 / $4,165.54
Moda Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$2,223.21 / $2,829.24 / $3,772.31
Oscar Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$3,048.80 / $3,048.80 / $3,048.80
Providence
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,786.07 / $2,784.31 / $4,204.51
Providence
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,952.73 / $2,969.16 / $4,485.78
United
Facility/Professional
Facility
Modifier
Low / Median / High Price
$2,093.00 / $6,000.00 / $13,134.00
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,848.66 / $2,541.90 / $3,928.39
Wellpoint
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,788.64 / $2,039.28 / $2,836.70