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Washington rates for HCPCS G0491

Dialysis procedure at a Medicare certified ESRD facility for acute kidney injury without ESRD

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,060.57 / $1,060.57 / $1,060.57
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$433.77 / $1,060.57 / $1,060.57
Asuris Northwest Health
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,517.00 / $1,517.00 / $1,517.00
Asuris Northwest Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$48.27 / $67.44 / $111.92
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$30.00 / $50.00 / $75.00
Pacific Source
Facility/Professional
Facility
Modifier
Low / Median / High Price
$79,999.20 / $79,999.20 / $79,999.20
Premera BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,517.00 / $1,517.00 / $1,517.00
Wellpoint
Facility/Professional
Professional
Modifier
Low / Median / High Price
$78.26 / $78.26 / $78.26