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Pennsylvania rates for HCPCS L8604

Injectable bulking agent, dextranomer/hyaluronic acid copolymer implant, urinary tract, 1 ml, includes shipping and necessary supplies

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$2,374.87 / $2,374.87 / $2,781.46
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$2,374.87 / $2,374.87 / $2,374.87
Martin's Point
Facility/Professional
Facility
Modifier
Low / Median / High Price
$2,374.87 / $2,781.46 / $3,450.15
Martin's Point
Facility/Professional
Professional
Modifier
Low / Median / High Price
$2,374.87 / $2,374.87 / $2,374.87