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Wisconsin rates for HCPCS D0120

Periodic Oral Evaluation

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$13.54 / $13.54 / $13.54
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$12.94 / $15.10 / $20.53
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$16.94 / $27.58 / $64.98
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$19.22 / $19.22 / $19.22
DeanCare
Facility/Professional
Facility
Modifier
Low / Median / High Price
$13.54 / $16.94 / $27.79
DeanCare
Facility/Professional
Professional
Modifier
Low / Median / High Price
$12.37 / $12.37 / $12.37
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$13.54 / $17.07 / $29.95
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$108.59 / $108.59 / $108.59
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$50.00 / $60.00 / $70.00
Prevea360
Facility/Professional
Facility
Modifier
Low / Median / High Price
$13.54 / $16.94 / $27.79
Prevea360
Facility/Professional
Professional
Modifier
Low / Median / High Price
$12.37 / $12.37 / $12.37
Quartz
Facility/Professional
Professional
Modifier
Low / Median / High Price
$21.92 / $40.22 / $56.10
Quartz
Facility/Professional
Facility
Modifier
Low / Median / High Price
$32.09 / $32.54 / $86.18
Quartz
Facility/Professional
Professional
Modifier
Low / Median / High Price
$73.22 / $86.20 / $108.59
Security Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$29.91 / $29.91 / $35.89