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Maryland rates for HCPCS V2628

Fabrication and fitting of ocular conformer

Insurance Carrier
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$125.13 / $271.02 / $376.13
CareFirst
Facility/Professional
Professional
Modifier
Low / Median / High Price
$224.59 / $224.59 / $224.59
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$175.28 / $175.28 / $175.28
Kaiser Permanente
Facility/Professional
Professional
Modifier
Low / Median / High Price
$321.35 / $376.13 / $547.76
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$164.50 / $182.18 / $260.70
Wellpoint
Facility/Professional
Professional
Modifier
Low / Median / High Price
$274.16 / $274.16 / $310.39