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Wisconsin rates for HCPCS A4928

Surgical mask, for dialysis, per 20

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1.25 / $1.25 / $1.25
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1.25 / $1.25 / $1.25
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1.00 / $1.00 / $1.42
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1.02 / $1.20 / $1.70
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.38 / $17.00 / $17.00
DeanCare
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1.25 / $1.25 / $1.25
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1.25 / $1.25 / $1.75
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$22.96 / $22.96 / $22.96
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$50.00 / $58.40 / $70.00
Prevea360
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1.25 / $1.25 / $1.38
Quartz
Facility/Professional
Facility
Modifier
Low / Median / High Price
$65.00 / $65.00 / $90.00
Quartz
Facility/Professional
Professional
Modifier
Low / Median / High Price
$17.00 / $17.00 / $17.00