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Utah rates for HCPCS A4680

Activated carbon filter for hemodialysis, each

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$19.95 / $19.95 / $19.95
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$19.95 / $33.88 / $44.67
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$36.31 / $36.31 / $36.31
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$30.20 / $44.67 / $128.82
Regence BlueShield
Facility/Professional
Professional
Modifier
Low / Median / High Price
$47.86 / $47.86 / $47.86
Select Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$112.20 / $112.20 / $134.90
U of Utah Health Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$38.02 / $41.69 / $46.77
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$17.38 / $28.84 / $47.86