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Illinois 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
$292.82 / $640.54 / $28,770.00
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$292.82 / $292.82 / $311.13
BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$418.42 / $2,160.21 / $4,711.70
BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$358.85 / $358.85 / $358.85
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
Hally Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$289.77 / $465.61 / $626.65
Hally Health
Facility/Professional
Facility
Modifier
Low / Median / High Price
$100.00 / $100.00 / $100.00
Hally Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$443.18 / $443.18 / $443.18
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$227.43 / $233.74 / $2,500.00
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$305.02 / $305.02 / $407.79