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Pennsylvania rates for HCPCS 77301

Intensity modulated radiotherapy plan, including dose-volume histograms for target and critical structure partial tolerance specifications

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
26
Low / Median / High Price
$407.38 / $912.01 / $1,621.81
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,621.81 / $2,398.83 / $9,772.37
Aetna
Facility/Professional
Professional
Modifier
26
Low / Median / High Price
$371.54 / $616.60 / $1,479.11
Aetna
Facility/Professional
Professional
Modifier
TC
Low / Median / High Price
$1,202.26 / $1,737.80 / $6,025.60
Ambetter
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,348.96 / $1,380.38 / $2,089.30
Ambetter
Facility/Professional
Professional
Modifier
26
Low / Median / High Price
$338.84 / $446.68 / $707.95
Capital Blue Cross
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,778.28 / $2,187.76 / $3,467.37
Capital Blue Cross
Facility/Professional
Professional
Modifier
26
Low / Median / High Price
$426.58 / $489.78 / $933.25
Capital Blue Cross
Facility/Professional
Professional
Modifier
TC
Low / Median / High Price
$1,348.96 / $1,737.80 / $2,754.23
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,445.44 / $2,187.76 / $3,548.13
Cigna
Facility/Professional
Professional
Modifier
26
Low / Median / High Price
$338.84 / $489.78 / $812.83
Cigna
Facility/Professional
Professional
Modifier
TC
Low / Median / High Price
$1,096.48 / $1,698.24 / $2,818.38
Emblem Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$2,511.89 / $2,691.53 / $3,388.44
Emblem Health
Facility/Professional
Professional
Modifier
26
Low / Median / High Price
$549.54 / $562.34 / $691.83
Emblem Health
Facility/Professional
Professional
Modifier
TC
Low / Median / High Price
$1,995.26 / $2,089.30 / $2,691.53
Geisinger
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,122.02 / $2,344.23 / $3,890.45
Geisinger
Facility/Professional
Professional
Modifier
26
Low / Median / High Price
$323.59 / $512.86 / $831.76
Geisinger
Facility/Professional
Professional
Modifier
TC
Low / Median / High Price
$812.83 / $1,862.09 / $3,090.30
Highmark BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$2,041.74 / $2,238.72 / $3,388.44
Highmark BCBS
Facility/Professional
Professional
Modifier
26
Low / Median / High Price
$426.58 / $478.63 / $630.96
Martin's Point
Facility/Professional
Facility
Modifier
26
Low / Median / High Price
$389.05 / $794.33 / $1,513.56
Martin's Point
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,659.59 / $2,570.40 / $5,888.44
Martin's Point
Facility/Professional
Professional
Modifier
26
Low / Median / High Price
$371.54 / $588.84 / $1,288.25
Martin's Point
Facility/Professional
Professional
Modifier
TC
Low / Median / High Price
$1,258.93 / $1,995.26 / $3,981.07
Oscar Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$2,570.40 / $3,630.78 / $4,265.80
UPMC Health Plan
Facility/Professional
Facility
Modifier
26
Low / Median / High Price
$407.38 / $416.87 / $446.68
UPMC Health Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$316.23 / $1,737.80 / $1,905.46
UPMC Health Plan
Facility/Professional
Professional
Modifier
26
Low / Median / High Price
$407.38 / $416.87 / $426.58
UPMC Health Plan
Facility/Professional
Professional
Modifier
TC
Low / Median / High Price
$1,318.26 / $1,348.96 / $1,479.11
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,445.44 / $2,089.30 / $3,548.13
United
Facility/Professional
Professional
Modifier
26
Low / Median / High Price
$371.54 / $478.63 / $794.33
United
Facility/Professional
Professional
Modifier
TC
Low / Median / High Price
$1,230.27 / $1,659.59 / $2,818.38