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Idaho rates for HCPCS A4642

Indium In-111 Satumomad Pendetide Diagnostic Perstudy Dose Up To 6 Millicuries

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,675.00 / $1,675.00 / $1,675.00
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,340.00 / $1,440.50 / $1,675.00
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,380.10 / $1,380.10 / $1,380.10
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,380.10 / $1,380.10 / $1,380.10
Moda Health
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,423.75 / $1,507.50 / $2,059.92
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$30.00 / $30.00 / $3,900.00
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,675.00 / $1,675.00 / $2,345.00