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Peritoneal Dialysate Concentrate, Powder Additive

Montana rates for HCPCS A4765

Dialysate concentrate, powder, additive for peritoneal dialysis, per packet

Rates data updated July 2026.

Facilitymedian $6 · 10th–90th $5$4570%20%40%10th90th$6Professionalmedian $5 · 10th–90th $5$2820%50%90th$5$2.0$10.0$50.0$200.0

Distribution of negotiated rates across all payers (price axis is log-scale). Facility and professional rates are different services and are charted separately. Need provider-level prices? Contact us.

Insurance Carrier
Aetna
Setting
Professional
Modifier
Global
Typical Low
$5.50
Median
$5.50
Typical High
$281.84
Providence
Setting
Facility
Modifier
Global
Typical Low
$5.50
Median
$5.89
Typical High
$457.09
Providence
Setting
Professional
Modifier
Global
Typical Low
$79.43
Median
$79.43
Typical High
$85.11