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Pennsylvania 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 / $347.58
Capital Blue Cross
Facility/Professional
Professional
Modifier
Low / Median / High Price
$365.17 / $365.17 / $365.17
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$481.11 / $481.11 / $481.11
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$175.28 / $175.28 / $175.28
Emblem Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$408.00 / $502.21 / $804.87
Highmark BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$246.59 / $246.59 / $246.59
Martin's Point
Facility/Professional
Professional
Modifier
Low / Median / High Price
$125.13 / $284.58 / $361.48
Oscar Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$254.90 / $254.90 / $254.90
Priority Health
Facility/Professional
Facility
Modifier
Low / Median / High Price
$481.11 / $481.11 / $481.11
Priority Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$175.28 / $175.28 / $175.28
UPMC Health Plan
Facility/Professional
Facility
Modifier
Low / Median / High Price
$261.08 / $261.08 / $347.58
UPMC Health Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$261.08 / $347.58 / $353.04
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$164.66 / $182.18 / $303.63