| Insurance Carrier | Facility/Professional | Modifier | Low Price | Median Price | High Price |
|---|---|---|---|---|---|
Aetna
| Professional | $35.00 | $35.00 | $35.00 | |
Medica
| Facility | $35.00 | $52.50 | $66.50 | |
Medica
| Professional | $53.27 | $53.27 | $53.27 | |
United
| Professional | $68.73 | $68.73 | $84.10 |
Dialysate Solution Any Concentration Of Dextrose Fluid Volume Greater Than 1999cc But Less Than Or Equal To 2999cc For Peritoneal Dialysis (Special Coverage Instructions Apply. See Mcm: 4270)
| Insurance Carrier | Facility/Professional | Modifier | Low Price | Median Price | High Price |
|---|---|---|---|---|---|
Aetna
| Professional | $35.00 | $35.00 | $35.00 | |
Medica
| Facility | $35.00 | $52.50 | $66.50 | |
Medica
| Professional | $53.27 | $53.27 | $53.27 | |
United
| Professional | $68.73 | $68.73 | $84.10 |