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Montana rates for HCPCS A9542

Indium In-111 ibritumomab tiuxetan, diagnostic, per study dose, up to 5 mCi

Insurance Carrier
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$3,486.00 / $3,759.04 / $3,759.04
BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$64,999.99 / $81,499.99 / $94,999.99
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$6,404.91 / $9,689.16 / $24,690.27
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$3,384.12 / $3,384.12 / $6,471.02
Providence
Facility/Professional
Facility
Modifier
Low / Median / High Price
$6,404.91 / $9,689.16 / $24,690.27
Providence
Facility/Professional
Professional
Modifier
Low / Median / High Price
$3,384.12 / $5,079.80 / $7,328.04
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$4,200.00 / $4,200.00 / $4,200.00