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Illinois rates for HCPCS G0458

Low dose rate (LDR) prostate brachytherapy services, composite rate

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$30.20 / $30.20 / $30.20
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$30.20 / $30.20 / $30.20
Hally Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$120.23 / $199.53 / $346.74
Hally Health
Facility/Professional
Facility
Modifier
Low / Median / High Price
$100.00 / $100.00 / $100.00
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$30.20 / $30.20 / $39.81