go back

Wisconsin rates for HCPCS A4617

Mouth Piece (Special Coverage Instructions Apply. See Cim: 60-4 And Mcm: 3312)

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$2.50 / $2.50 / $2.50
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1.27 / $2.50 / $3.71
Anthem BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$4.33 / $4.33 / $7.88
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$2.21 / $4.03 / $5.32
CareSource
Facility/Professional
Facility
Modifier
Low / Median / High Price
$3.11 / $9.27 / $9.27
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$11.71 / $13.69 / $21.00
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1.77 / $6.09 / $8.19
DeanCare
Facility/Professional
Facility
Modifier
Low / Median / High Price
$2.22 / $3.57 / $4.98
DeanCare
Facility/Professional
Professional
Modifier
Low / Median / High Price
$2.87 / $2.87 / $5.20
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$2.45 / $4.33 / $90.00
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1.84 / $2.16 / $5.63
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$2.27 / $55.00 / $85.00
Prevea360
Facility/Professional
Facility
Modifier
Low / Median / High Price
$2.22 / $3.57 / $5.20
Prevea360
Facility/Professional
Professional
Modifier
Low / Median / High Price
$2.87 / $2.87 / $5.20
Quartz
Facility/Professional
Professional
Modifier
Low / Median / High Price
$4.33 / $6.79 / $11.07
Quartz
Facility/Professional
Facility
Modifier
Low / Median / High Price
$8.46 / $8.46 / $90.00
Quartz
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1.77 / $19.04 / $44.16
Security Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$4.33 / $4.33 / $4.33
Security Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$4.33 / $4.33 / $4.33
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1.44 / $2.16 / $4.13