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Washington 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
$35.00 / $35.00 / $79.45
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$35.00 / $35.00 / $35.00
Asuris Northwest Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1.21 / $13.75 / $40.00
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$30.00 / $50.00 / $75.00
Pacific Source
Facility/Professional
Facility
Modifier
Low / Median / High Price
$79,999.20 / $79,999.20 / $79,999.20
Wellpoint
Facility/Professional
Professional
Modifier
Low / Median / High Price
$15.09 / $15.09 / $15.09