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Illinois rates for HCPCS A4726

Dialysate solution, any concentration of dextrose, fluid volume greater than 5999 cc, for peritoneal dialysis

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
$26.74 / $59.40 / $59.40
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