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Utah rates for HCPCS V2628

Fabrication and fitting of ocular conformer

Insurance Carrier
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$117.61 / $193.54 / $397.54
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$175.28 / $175.28 / $175.28
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$60.00 / $396.00 / $479.85
Regence BlueShield
Facility/Professional
Professional
Modifier
Low / Median / High Price
$270.76 / $340.83 / $340.83
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$142.63 / $182.18 / $274.43