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Washington rates for HCPCS V2628

Fabrication and fitting of ocular conformer

Insurance Carrier
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$150.79 / $317.99 / $401.59
Asuris Northwest Health
Facility/Professional
Facility
Modifier
Low / Median / High Price
$426.34 / $619.47 / $1,957.92
Asuris Northwest Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$372.48 / $486.60 / $2,716.65
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$175.28 / $175.28 / $175.28
Kaiser Permanente
Facility/Professional
Facility
Modifier
Low / Median / High Price
$256.06 / $450.17 / $1,181.22
Kaiser Permanente
Facility/Professional
Professional
Modifier
Low / Median / High Price
$258.51 / $449.28 / $813.76
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$335.93 / $410.58 / $410.58
Pacific Source
Facility/Professional
Facility
Modifier
Low / Median / High Price
$475.48 / $475.48 / $486.90
Premera BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$426.34 / $426.34 / $426.34
Premera BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$404.16 / $461.22 / $546.79
Regence BlueShield
Facility/Professional
Professional
Modifier
Low / Median / High Price
$389.04 / $413.87 / $535.59
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$168.44 / $182.18 / $347.58