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South Dakota rates for HCPCS A9521

Technetium Tc-99m exametazime, diagnostic, per study dose, up to 25 mCi

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$2,041.74 / $2,041.74 / $2,041.74
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,659.59 / $1,737.80 / $2,041.74
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,737.80 / $1,737.80 / $2,344.23
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$2,041.74 / $2,630.27 / $5,128.61
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,698.24 / $1,698.24 / $1,949.84
Midlands
Facility/Professional
Professional
Modifier
Low / Median / High Price
$2,344.23 / $2,344.23 / $2,344.23
Sanford Health Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,737.80 / $1,737.80 / $1,737.80
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,698.24 / $1,698.24 / $1,949.84
Wellmark
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,698.24 / $1,698.24 / $1,698.24