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Montana rates for HCPCS A4714

Treated water (deionized, distilled, or reverse osmosis) for peritoneal dialysis, per gallon

Insurance Carrier
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1.20 / $2.00 / $2.00
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$13.99 / $13.99 / $13.99
Providence
Facility/Professional
Facility
Modifier
Low / Median / High Price
$2.00 / $2.00 / $3.08
Providence
Facility/Professional
Professional
Modifier
Low / Median / High Price
$13.99 / $1,800,000.00 / $2,400,000.00
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$33.02 / $35.08 / $35.08