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Wisconsin rates for HCPCS Q4233

SurFactor or NuDyn, per 0.5 cc

Insurance Carrier
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$5,120.10 / $5,120.10 / $5,120.10
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$487.50 / $487.50 / $487.50
DeanCare
Facility/Professional
Facility
Modifier
Low / Median / High Price
$5,120.10 / $5,120.10 / $5,120.10
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$100.00 / $5,120.10 / $5,120.10
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$50.00 / $58.40 / $85.00
Prevea360
Facility/Professional
Facility
Modifier
Low / Median / High Price
$5,120.10 / $5,120.10 / $5,120.10
Quartz
Facility/Professional
Professional
Modifier
Low / Median / High Price
$5,900.00 / $5,900.00 / $5,900.00
Quartz
Facility/Professional
Facility
Modifier
Low / Median / High Price
$65.00 / $65.00 / $100.00