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Pennsylvania rates for HCPCS A4765

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

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$5.45 / $5.45 / $5.45
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$5.45 / $5.45 / $5.45
Capital Blue Cross
Facility/Professional
Professional
Modifier
Low / Median / High Price
$17.11 / $17.76 / $17.76
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$64.00 / $64.00 / $64.00
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$4.37 / $4.37 / $4.37
Martin's Point
Facility/Professional
Professional
Modifier
Low / Median / High Price
$5.45 / $5.45 / $5.45
Priority Health
Facility/Professional
Facility
Modifier
Low / Median / High Price
$64.00 / $64.00 / $64.00
Priority Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$4.37 / $4.37 / $4.37