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Idaho rates for HCPCS A9513

Lutetium Lu 177 Dotate Therapeutic 1 Millicurie(Reinstated Code) Supply Of Radiopharmaceutical Diagnostic Imaging Agent Technitium Tc-99m Mebrofenin Per Mci (Old Description Deleted 12/31/2005)

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$305.02 / $305.02 / $330.52
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$292.82 / $311.13 / $314.79
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$311.13 / $311.13 / $311.13
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$311.13 / $311.13 / $311.13
Moda Health
Facility/Professional
Facility
Modifier
Low / Median / High Price
$314.79 / $333.68 / $398.25
Moda Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$399.89 / $399.89 / $399.89
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$30.00 / $255.92 / $652.33
Regence BlueShield
Facility/Professional
Facility
Modifier
Low / Median / High Price
$310.32 / $443.31 / $753.63
Regence BlueShield
Facility/Professional
Professional
Modifier
Low / Median / High Price
$417.28 / $417.28 / $434.66
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$305.02 / $305.02 / $488.03