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Wisconsin rates for HCPCS A4714

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

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$2.00 / $2.00 / $2.00
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$2.00 / $2.00 / $2.00
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$2.00 / $2.00 / $41.66
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$145.97 / $193.85 / $261.69
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$13.99 / $13.99 / $75.94
DeanCare
Facility/Professional
Facility
Modifier
Low / Median / High Price
$2.00 / $2.00 / $2.00
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$2.00 / $2.00 / $2.80
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$30.66 / $33.35 / $56.76
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$50.00 / $58.40 / $70.00
Prevea360
Facility/Professional
Facility
Modifier
Low / Median / High Price
$2.00 / $2.00 / $2.20
Quartz
Facility/Professional
Facility
Modifier
Low / Median / High Price
$65.00 / $65.00 / $90.00
Quartz
Facility/Professional
Professional
Modifier
Low / Median / High Price
$13.99 / $13.99 / $13.99
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$22.19 / $33.29 / $56.48