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Washington rates for HCPCS 67028

Intravitreal injection of a pharmacologic agent (separate procedure)

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$136.72 / $936.94 / $7,920.26
Aetna
Facility/Professional
Facility
Modifier
50
Low / Median / High Price
$549.45 / $1,307.34 / $8,884.00
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$90.54 / $128.51 / $325.25
Aetna
Facility/Professional
Professional
Modifier
50
Low / Median / High Price
$158.16 / $204.33 / $777.60
Ambetter
Facility/Professional
Professional
Modifier
Low / Median / High Price
$110.91 / $149.72 / $228.14
Ambetter
Facility/Professional
Professional
Modifier
50
Low / Median / High Price
$224.59 / $224.59 / $224.59
Asuris Northwest Health
Facility/Professional
Facility
Modifier
Low / Median / High Price
$101.84 / $899.60 / $1,835.89
Asuris Northwest Health
Facility/Professional
Facility
Modifier
50
Low / Median / High Price
$1,011.81 / $1,011.81 / $1,011.81
Asuris Northwest Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$152.46 / $242.74 / $1,700.65
Asuris Northwest Health
Facility/Professional
Professional
Modifier
50
Low / Median / High Price
$218.90 / $276.63 / $478.50
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$138.68 / $138.68 / $479.00
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$101.50 / $173.36 / $350.64
Kaiser Permanente
Facility/Professional
Facility
Modifier
Low / Median / High Price
$70.75 / $152.77 / $272.81
Kaiser Permanente
Facility/Professional
Facility
Modifier
50
Low / Median / High Price
$905.03 / $995.60 / $2,556.96
Kaiser Permanente
Facility/Professional
Professional
Modifier
Low / Median / High Price
$71.19 / $156.83 / $264.14
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$27.16 / $152.09 / $264.27
Pacific Source
Facility/Professional
Facility
Modifier
Low / Median / High Price
$140.02 / $194.70 / $231.20
Premera BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$101.84 / $149.49 / $154.01
Premera BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$147.44 / $212.94 / $287.83
Regence BlueShield
Facility/Professional
Facility
Modifier
Low / Median / High Price
$674.54 / $959.75 / $1,835.89
Regence BlueShield
Facility/Professional
Facility
Modifier
50
Low / Median / High Price
$803.12 / $803.12 / $1,011.81
Regence BlueShield
Facility/Professional
Professional
Modifier
Low / Median / High Price
$122.43 / $210.24 / $278.18
United
Facility/Professional
Facility
Modifier
Low / Median / High Price
$118.00 / $300.76 / $1,875.00
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$128.71 / $194.83 / $307.41