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Washington rates for HCPCS A6404

Gauze, nonimpregnated, sterile, pad size more than 48 sq in, without adhesive border, each dressing

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$0.28 / $0.64 / $0.66
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.15 / $0.28 / $0.48
Asuris Northwest Health
Facility/Professional
Facility
Modifier
Low / Median / High Price
$0.46 / $85.00 / $90.00
Asuris Northwest Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.46 / $1.11 / $5.30
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.60 / $0.60 / $0.60
Kaiser Permanente
Facility/Professional
Facility
Modifier
Low / Median / High Price
$0.31 / $0.70 / $0.89
Kaiser Permanente
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.42 / $0.70 / $0.89
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1.37 / $1.68 / $1.68
Pacific Source
Facility/Professional
Facility
Modifier
Low / Median / High Price
$0.55 / $0.66 / $0.76
Pacific Source
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.76 / $0.76 / $0.76
Premera BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$0.45 / $0.45 / $0.46
Premera BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.46 / $0.66 / $0.91
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.19 / $0.22 / $0.36
Wellpoint
Facility/Professional
Professional
Modifier
Low / Median / High Price
$6.38 / $6.38 / $6.38