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Utah rates for HCPCS A4721

Dialysate solution, any concentration of dextrose, fluid volume greater than 999 cc but less than or equal to 1999 cc, for peritoneal dialysis

Facilitymedian $20 · 10th–90th $20–$200%50%100%$20Professionalmedian $20 · 10th–90th $20–$200%50%$20$5.0$10.0$20.0$50.0

Distribution of negotiated rates across all payers (price axis is log-scale). Facility and professional rates are different services and are charted separately. Small sample — interpret with caution. Need provider-level prices? Contact us.

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Typical Low / Median / Typical High
$19.95 / $19.95 / $19.95
Aetna
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$19.95 / $19.95 / $19.95
Molina
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$30.20 / $44.67 / $60.26
Select Health
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$3.39 / $3.39 / $3.39