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South Dakota rates for HCPCS V2628

Fabrication and fitting of ocular conformer

Insurance Carrier
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$295.44 / $393.92 / $475.48
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$423.38 / $423.38 / $529.22
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$393.92 / $481.58 / $803.56
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$182.18 / $242.90 / $2,424.76
Midlands
Facility/Professional
Facility
Modifier
Low / Median / High Price
$384.00 / $535.59 / $949.46
Midlands
Facility/Professional
Professional
Modifier
Low / Median / High Price
$415.04 / $438.65 / $484.94
Sanford Health Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$406.14 / $486.90 / $612.23
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$142.63 / $193.98 / $404.84
Wellmark
Facility/Professional
Professional
Modifier
Low / Median / High Price
$552.00 / $552.00 / $552.00