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Illinois rates for HCPCS A4725

Dialysate Solution Any Concentration Of Dextrose Fluid Volume Greater Than 4999cc But Less Than Or Equal To 5999cc For Peritoneal Dialysis (Special Coverage Instructions Apply. See Mcm: 4270)

Insurance Carrier
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$35.00 / $35.00 / $35.00
BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$29.70 / $29.70 / $29.70
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$64.00 / $64.00 / $64.00
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$34.69 / $46.74 / $46.74
Hally Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$100.00 / $125.00 / $345.40
Hally Health
Facility/Professional
Facility
Modifier
Low / Median / High Price
$100.00 / $100.00 / $100.00
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$30.00 / $30.00 / $2,500.00