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Washington rates for HCPCS V2104

Spherocylinder, single vision, plano to plus or minus 4.00d sphere, 2.12 to 4.00d cylinder, per lens

Insurance Carrier
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$18.20 / $36.31 / $42.66
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$21.88 / $21.88 / $21.88
Kaiser Permanente
Facility/Professional
Facility
Modifier
Low / Median / High Price
$31.62 / $51.29 / $120.23
Kaiser Permanente
Facility/Professional
Professional
Modifier
Low / Median / High Price
$31.62 / $51.29 / $100.00
Pacific Source
Facility/Professional
Facility
Modifier
Low / Median / High Price
$51.29 / $52.48 / $57.54
Premera BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$10,000.00 / $10,000.00 / $10,000.00
Premera BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$10,000.00 / $10,000.00 / $10,000.00
United
Facility/Professional
Facility
Modifier
Low / Median / High Price
$74.13 / $74.13 / $74.13
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$17.78 / $22.39 / $42.66
Wellpoint
Facility/Professional
Professional
Modifier
Low / Median / High Price
$45.71 / $45.71 / $60.26