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Wisconsin rates for HCPCS A4736

Topical Anesthetic For Dialysis Per Gram (Special Coverage Instructions Apply. See Mcm: 4270)

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$15.00 / $15.00 / $15.00
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$15.00 / $15.00 / $15.00
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1.30 / $1.30 / $1.30
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$64.00 / $64.00 / $64.00
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1.68 / $1.68 / $1.68
DeanCare
Facility/Professional
Facility
Modifier
Low / Median / High Price
$15.00 / $15.00 / $15.00
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$15.00 / $15.00 / $21.00
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$18.00 / $18.00 / $18.00
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$50.00 / $58.40 / $70.00
Prevea360
Facility/Professional
Facility
Modifier
Low / Median / High Price
$15.00 / $15.00 / $16.50
Quartz
Facility/Professional
Facility
Modifier
Low / Median / High Price
$65.00 / $65.00 / $90.00
Quartz
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1.68 / $1.68 / $1.68