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South Dakota rates for HCPCS A9569

Technetium Tx-99m Exametazime Labeled Autologous White Blood Cells Diagnostic Per Study Dose

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$2,056.76 / $2,056.76 / $2,056.76
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,748.25 / $2,056.76 / $2,056.76
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,748.25 / $1,748.25 / $2,436.56
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$2,056.76 / $2,647.04 / $5,071.96
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,713.97 / $1,713.97 / $1,953.92
Midlands
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,560.48 / $2,484.59 / $2,968.23
Midlands
Facility/Professional
Professional
Modifier
Low / Median / High Price
$2,012.42 / $2,517.39 / $4,156.47
Sanford Health Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,748.25 / $1,748.25 / $1,748.25
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,713.97 / $1,713.97 / $1,885.37
Wellmark
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,713.97 / $1,713.97 / $1,713.97