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South Dakota rates for HCPCS V2627

Scleral Cover Shell (Special Coverage Instructions Apply. See Cim: 65-3)

Insurance Carrier
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,251.23 / $1,437.92 / $1,962.50
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,990.13 / $1,990.13 / $2,487.66
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,251.23 / $2,009.60 / $3,316.63
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$771.56 / $800.61 / $10,207.25
Midlands
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,677.00 / $1,701.21 / $3,015.77
Midlands
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,393.30 / $1,540.31 / $1,713.04
Sanford Health Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,676.29 / $2,009.60 / $2,526.87
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$604.12 / $771.56 / $1,670.95
Wellmark
Facility/Professional
Professional
Modifier
Low / Median / High Price
$3,333.00 / $3,333.00 / $3,333.00