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Nebraska rates for HCPCS 21085

Impression and custom preparation; oral surgical splint

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$451.58 / $7,119.04 / $20,928.72
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$451.58 / $630.41 / $2,703.14
BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$3,271.26 / $4,302.59 / $8,322.61
BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$476.88 / $875.19 / $1,295.48
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$186.20 / $186.20 / $186.20
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$945.36 / $1,383.88 / $2,067.94
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$451.58 / $858.00 / $1,647.23
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$869.10 / $1,474.13 / $3,632.32
Midlands
Facility/Professional
Facility
Modifier
Low / Median / High Price
$209.07 / $1,276.19 / $1,808.69
Midlands
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,050.81 / $1,400.99 / $1,806.85
United
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,031.00 / $1,775.00 / $4,406.00
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$869.10 / $1,557.97 / $1,871.91