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Washington rates for HCPCS E1011

Modification to pediatric size wheelchair, width adjustment package (not to be dispensed with initial chair)

Insurance Carrier
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$574.00 / $574.00 / $574.00
Asuris Northwest Health
Facility/Professional
Facility
Modifier
Low / Median / High Price
$100.00 / $1,423.10 / $1,423.10
Asuris Northwest Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$292.00 / $292.00 / $403.00
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$424.00 / $424.00 / $424.00
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$360.40 / $424.00 / $457.97
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$45.00 / $60.00 / $93.50
Pacific Source
Facility/Professional
Facility
Modifier
Low / Median / High Price
$190.74 / $190.74 / $190.74
Pacific Source
Facility/Professional
Professional
Modifier
Low / Median / High Price
$190.74 / $190.74 / $190.74