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South Dakota rates for HCPCS A9542

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

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$2,696.25 / $2,696.25 / $2,696.25
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$2,696.25 / $2,867.68 / $3,486.00
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$3,384.12 / $3,384.12 / $5,917.35
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$4,100.78 / $4,846.38 / $7,857.44
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$3,990.00 / $4,200.00 / $4,620.00
Midlands
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,197.03 / $5,971.32 / $6,805.94
Midlands
Facility/Professional
Professional
Modifier
Low / Median / High Price
$5,971.32 / $6,113.65 / $10,094.31
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$4,200.00 / $4,200.00 / $4,620.00
Wellmark
Facility/Professional
Professional
Modifier
Low / Median / High Price
$798.02 / $798.02 / $798.02