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Washington 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
$1,423.75 / $2,463.09 / $3,374.29
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,356.75 / $1,423.75 / $1,668.30
Asuris Northwest Health
Facility/Professional
Facility
Modifier
Low / Median / High Price
$2,361.69 / $8,883.66 / $8,883.66
Asuris Northwest Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,127.50 / $10,274.74 / $14,610.30
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,380.10 / $1,380.10 / $2,760.20
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,380.10 / $1,380.10 / $1,380.10
Kaiser Permanente
Facility/Professional
Facility
Modifier
Low / Median / High Price
$510.97 / $1,075.61 / $4,103.39
Kaiser Permanente
Facility/Professional
Professional
Modifier
Low / Median / High Price
$510.97 / $1,075.61 / $4,103.39
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$75.00 / $75.00 / $75.00
Pacific Source
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,610.40 / $1,610.40 / $3,053.36
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,675.00 / $1,675.00 / $2,010.00