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Utah rates for HCPCS 21077

Impression & Preparation Orbital Prosthesis

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$2,961.88 / $2,961.88 / $3,395.04
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,645.06 / $2,961.88 / $9,823.40
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$2,034.08 / $2,930.28 / $4,037.00
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$185.15 / $1,237.54 / $2,029.12
Regence BlueShield
Facility/Professional
Facility
Modifier
Low / Median / High Price
$8,413.68 / $11,103.62 / $16,181.16
Regence BlueShield
Facility/Professional
Professional
Modifier
Low / Median / High Price
$2,294.77 / $3,230.11 / $6,136.26
United
Facility/Professional
Facility
Modifier
Low / Median / High Price
$2,912.00 / $7,693.00 / $13,847.00
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,901.48 / $2,433.13 / $3,841.81