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Washington 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
$164.60 / $164.60 / $164.60
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$158.51 / $180.63 / $352.67
Asuris Northwest Health
Facility/Professional
Facility
Modifier
Low / Median / High Price
$162.11 / $168.43 / $675.45
Asuris Northwest Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$168.43 / $168.43 / $196.39
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$175.41 / $175.41 / $350.82
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$175.41 / $175.41 / $175.41
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$132.77 / $152.12 / $331.92
Pacific Source
Facility/Professional
Facility
Modifier
Low / Median / High Price
$25.00 / $134.53 / $134.53
Premera BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$187.04 / $187.04 / $187.04
Premera BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$151.50 / $177.69 / $196.39
Regence BlueShield
Facility/Professional
Facility
Modifier
Low / Median / High Price
$168.43 / $168.43 / $168.43
Regence BlueShield
Facility/Professional
Professional
Modifier
Low / Median / High Price
$168.43 / $168.43 / $168.43
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$156.69 / $177.07 / $188.04