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Utah 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
$446.68 / $446.68 / $446.68
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,737.80 / $2,238.72 / $10,232.93
Aetna
Facility/Professional
Professional
Modifier
26
Low / Median / High Price
$371.54 / $707.95 / $1,737.80
Aetna
Facility/Professional
Professional
Modifier
TC
Low / Median / High Price
$1,258.93 / $1,778.28 / $3,311.31
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,778.28 / $2,630.27 / $3,388.44
Cigna
Facility/Professional
Professional
Modifier
26
Low / Median / High Price
$501.19 / $549.54 / $741.31
Cigna
Facility/Professional
Professional
Modifier
TC
Low / Median / High Price
$1,348.96 / $2,137.96 / $2,754.23
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$32.36 / $60.26 / $3,467.37
Regence BlueShield
Facility/Professional
Facility
Modifier
26
Low / Median / High Price
$2,290.87 / $2,290.87 / $2,290.87
Regence BlueShield
Facility/Professional
Professional
Modifier
Low / Median / High Price
$2,754.23 / $3,548.13 / $3,981.07
Regence BlueShield
Facility/Professional
Professional
Modifier
26
Low / Median / High Price
$616.60 / $724.44 / $870.96
Regence BlueShield
Facility/Professional
Professional
Modifier
TC
Low / Median / High Price
$2,137.96 / $2,454.71 / $3,019.95
Select Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,819.70 / $3,311.31 / $4,168.69
Select Health
Facility/Professional
Professional
Modifier
26
Low / Median / High Price
$398.11 / $776.25 / $933.25
Select Health
Facility/Professional
Professional
Modifier
TC
Low / Median / High Price
$1,412.54 / $2,511.89 / $3,162.28
U of Utah Health Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$602.56 / $2,137.96 / $3,388.44
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,949.84 / $2,454.71 / $3,311.31
United
Facility/Professional
Professional
Modifier
26
Low / Median / High Price
$457.09 / $524.81 / $724.44
United
Facility/Professional
Professional
Modifier
TC
Low / Median / High Price
$1,698.24 / $1,995.26 / $2,630.27