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Wisconsin rates for HCPCS B4164

Parenteral Nutrition Solution: Carbohydrates (Dextrose) 50% Or Less (500 Ml = 1 Unit) - Homemix (Special Coverage Instructions Apply. See Cim: 65-10 And Mcm: 2130 4450)

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$18.07 / $18.07 / $18.07
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$17.13 / $18.07 / $71.14
Anthem BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$24.66 / $24.66 / $40.69
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$22.93 / $22.93 / $27.12
CareSource
Facility/Professional
Facility
Modifier
Low / Median / High Price
$22.19 / $52.77 / $52.77
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$66.68 / $77.92 / $119.54
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$20.35 / $35.63 / $46.66
DeanCare
Facility/Professional
Facility
Modifier
Low / Median / High Price
$17.13 / $24.66 / $25.89
DeanCare
Facility/Professional
Professional
Modifier
Low / Median / High Price
$8.82 / $8.82 / $8.82
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$18.07 / $24.66 / $115.41
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$12.30 / $27.88 / $74.87
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$65.00 / $65.00 / $90.00
Prevea360
Facility/Professional
Facility
Modifier
Low / Median / High Price
$17.13 / $24.66 / $25.89
Prevea360
Facility/Professional
Professional
Modifier
Low / Median / High Price
$8.82 / $8.82 / $8.82
Quartz
Facility/Professional
Professional
Modifier
Low / Median / High Price
$24.66 / $37.52 / $74.27
Quartz
Facility/Professional
Facility
Modifier
Low / Median / High Price
$48.16 / $50.06 / $115.41
Quartz
Facility/Professional
Professional
Modifier
Low / Median / High Price
$20.35 / $20.35 / $20.35
Security Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$24.66 / $24.66 / $24.66
Security Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$24.66 / $24.66 / $24.66
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$9.63 / $24.60 / $75.15