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Wisconsin rates for HCPCS B4197

Parenteral Nutrition Solution; Compounded Amino Acid And Carbohydrates With Electrolytes Trace Elements And Vitamins Including Preparation Any Strength 74 To 100 Grams Of Protein - Premix (Special Coverage Instructions Apply. See Cim: 65-10 And Mcm: 2130 4450)

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$297.35 / $297.35 / $297.35
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$281.89 / $297.35 / $1,170.59
Anthem BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$405.72 / $405.72 / $669.44
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$377.32 / $377.32 / $446.29
CareSource
Facility/Professional
Facility
Modifier
Low / Median / High Price
$365.15 / $365.15 / $868.24
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,090.35 / $1,274.17 / $1,954.60
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$170.00 / $587.80 / $767.85
DeanCare
Facility/Professional
Facility
Modifier
Low / Median / High Price
$281.89 / $405.72 / $426.01
DeanCare
Facility/Professional
Professional
Modifier
Low / Median / High Price
$145.63 / $145.63 / $145.63
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$297.35 / $405.72 / $1,898.77
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$202.41 / $458.80 / $1,232.07
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$65.00 / $65.00 / $90.00
Prevea360
Facility/Professional
Facility
Modifier
Low / Median / High Price
$281.89 / $405.72 / $426.01
Prevea360
Facility/Professional
Professional
Modifier
Low / Median / High Price
$145.63 / $145.63 / $145.63
Quartz
Facility/Professional
Professional
Modifier
Low / Median / High Price
$405.72 / $608.58 / $958.32
Quartz
Facility/Professional
Facility
Modifier
Low / Median / High Price
$792.42 / $823.61 / $1,898.77
Quartz
Facility/Professional
Professional
Modifier
Low / Median / High Price
$170.00 / $170.00 / $170.00
Security Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$405.72 / $405.72 / $405.72
Security Health
Facility/Professional
Facility
Modifier
Low / Median / High Price
$353.94 / $353.94 / $353.94
Security Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$405.72 / $405.72 / $405.72
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$158.47 / $405.72 / $1,232.07