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Wisconsin rates for HCPCS A4221

Supplies For Maintenance Of Non-Insulin Drug Infusion Catheter Per Week (List Drug Separately)(Desc Revised 1/1/2017)

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$15.50 / $15.50 / $41.82
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$9.28 / $15.50 / $22.87
Anthem BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$25.19 / $25.19 / $41.56
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$23.43 / $25.19 / $28.71
CareSource
Facility/Professional
Facility
Modifier
Low / Median / High Price
$25.19 / $37.79 / $53.91
CareSource
Facility/Professional
Professional
Modifier
Low / Median / High Price
$26.45 / $31.37 / $58.40
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$67.58 / $78.98 / $104.97
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$15.09 / $36.56 / $47.40
DeanCare
Facility/Professional
Facility
Modifier
Low / Median / High Price
$15.11 / $20.27 / $25.19
DeanCare
Facility/Professional
Professional
Modifier
Low / Median / High Price
$18.11 / $18.11 / $25.19
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$15.11 / $20.27 / $26.45
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$13.15 / $15.52 / $36.68
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$33.66 / $65.00 / $85.00
Prevea360
Facility/Professional
Facility
Modifier
Low / Median / High Price
$15.11 / $20.27 / $25.19
Prevea360
Facility/Professional
Professional
Modifier
Low / Median / High Price
$18.11 / $18.11 / $25.19
Quartz
Facility/Professional
Professional
Modifier
Low / Median / High Price
$25.19 / $42.62 / $75.00
Quartz
Facility/Professional
Facility
Modifier
Low / Median / High Price
$48.92 / $51.14 / $120.00
Quartz
Facility/Professional
Professional
Modifier
Low / Median / High Price
$15.09 / $110.07 / $125.45
Security Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$28.41 / $28.41 / $28.41
Security Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$28.41 / $28.41 / $28.41
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$11.64 / $14.11 / $24.88