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Utah rates for HCPCS V2104

Spherocylinder, single vision, plano to plus or minus 4.00d sphere, 2.12 to 4.00d cylinder, per lens

Insurance Carrier
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$18.20 / $38.90 / $44.67
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$21.88 / $21.88 / $21.88
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$30.20 / $41.69 / $56.23
Select Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$48.98 / $57.54 / $57.54
U of Utah Health Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$52.48 / $58.88 / $58.88
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$17.78 / $22.39 / $33.88