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Ohio rates for HCPCS A4726

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

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$64.57 / $64.57 / $64.57
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$34.67 / $34.67 / $34.67
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$20.42 / $22.91 / $34.67
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$64.57 / $64.57 / $64.57
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$2,238.72 / $2,238.72 / $2,238.72
Medical Mutual of Ohio
Facility/Professional
Facility
Modifier
Low / Median / High Price
$64.57 / $64.57 / $64.57
Medical Mutual of Ohio
Facility/Professional
Professional
Modifier
Low / Median / High Price
$2,238.72 / $2,238.72 / $2,238.72
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$33.11 / $50.12 / $60.26
SummaCare
Facility/Professional
Professional
Modifier
Low / Median / High Price
$50.12 / $60.26 / $75.86