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South Dakota rates for HCPCS A9515

Choline C-11 Diagnostic Per Study Dose Up To 20 Millicuries (Reinstated 01/01/2017) Supply Of Radiopharmaceutical Diagnostic Imaging Agent Technitium Tc-99m Pentetate Per Mci (Del 12/31/2005)

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$6,000.00 / $6,000.00 / $6,000.00
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$5,100.00 / $6,000.00 / $6,000.00
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$5,500.13 / $5,555.13 / $6,875.16
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$6,000.00 / $9,126.00 / $10,140.00
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$5,000.00 / $5,000.00 / $22,800.00
Midlands
Facility/Professional
Facility
Modifier
Low / Median / High Price
$3,094.41 / $4,125.88 / $4,971.68
Sanford Health Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$5,100.00 / $5,100.00 / $5,100.00
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$5,000.00 / $5,000.00 / $5,500.00
Wellmark
Facility/Professional
Professional
Modifier
Low / Median / High Price
$5,400.00 / $5,400.00 / $5,400.00