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Washington rates for HCPCS D0120

Periodic Oral Evaluation

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$20.53 / $20.53 / $20.53
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$14.10 / $17.38 / $20.53
Asuris Northwest Health
Facility/Professional
Facility
Modifier
Low / Median / High Price
$32.09 / $86.18 / $86.18
Asuris Northwest Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$25.23 / $108.59 / $143.10
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$19.22 / $19.22 / $19.22
Kaiser Permanente
Facility/Professional
Facility
Modifier
Low / Median / High Price
$16.43 / $34.00 / $56.92
Kaiser Permanente
Facility/Professional
Professional
Modifier
Low / Median / High Price
$15.50 / $28.75 / $43.73
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$45.00 / $50.00 / $75.00
Pacific Source
Facility/Professional
Facility
Modifier
Low / Median / High Price
$23.83 / $33.52 / $34.17
Premera BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$38.00 / $49.35 / $49.35
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$44.00 / $44.00 / $45.00
Wellpoint
Facility/Professional
Professional
Modifier
Low / Median / High Price
$27.00 / $27.00 / $27.00