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Montana rates for HCPCS A4642

Indium In-111 satumomab pendetide, diagnostic, per study dose, up to 6 mCi

Insurance Carrier
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,390.25 / $1,390.25 / $1,390.25
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$2,624.42 / $2,737.13 / $9,972.79
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,380.10 / $1,380.10 / $2,638.99
Providence
Facility/Professional
Facility
Modifier
Low / Median / High Price
$2,624.42 / $2,737.13 / $9,972.79
Providence
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,531.77 / $2,034.19 / $2,638.99
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,675.00 / $1,675.00 / $1,675.00