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Texas rates for HCPCS A4642

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

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,340.00 / $1,373.50 / $5,038.39
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,340.00 / $1,373.50 / $1,423.75
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
Lucent Health
Facility/Professional
Facility
Modifier
Low / Median / High Price
$3,225.19 / $9,207.50 / $9,207.50
Lucent Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$10,274.74 / $10,274.74 / $14,197.28
Moda Health
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,373.50 / $1,964.11 / $3,803.46
Moda Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,534.18 / $1,534.18 / $1,534.18
Providence
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,380.10 / $1,380.10 / $3,175.26
Providence
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,380.10 / $1,380.10 / $1,380.10
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,675.00 / $1,675.00 / $1,675.00
Wellpoint
Facility/Professional
Professional
Modifier
Low / Median / High Price
$268.25 / $268.25 / $362.14