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South Carolina rates for HCPCS A4724

Dialysate solution, any concentration of dextrose, fluid volume greater than 3999 cc, but less than or equal to 4999 cc

Insurance Carrier
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$18.41 / $18.41 / $18.41
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$64.00 / $64.00 / $64.00
Medcost
Facility/Professional
Facility
Modifier
Low / Median / High Price
$18.41 / $18.41 / $31.30
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$30.00 / $30.00 / $30.00