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Montana rates for HCPCS 90697

Diphtheria, tetanus toxoids, acellular pertussis vaccine, inactivated poliovirus vaccine, Haemophilus influenzae type b PRP-OMP conjugate vaccine, and hepatitis B vaccine (DTaP-IPV-Hib-HepB), for intramuscular use

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$207.58 / $207.58 / $207.58
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$154.01 / $164.60 / $250.00
BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$64,999.99 / $81,499.99 / $94,999.99
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$175.41 / $175.41 / $175.41
Providence
Facility/Professional
Professional
Modifier
Low / Median / High Price
$175.41 / $175.41 / $181.02
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$177.07 / $177.07 / $188.04