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Indiana 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
$287.08 / $704.28 / $1,291.85
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$292.82 / $292.82 / $303.80
Anthem BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$316.99 / $610.04 / $808.30
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$237.50 / $237.50 / $588.67
CareSource
Facility/Professional
Facility
Modifier
Low / Median / High Price
$432.38 / $432.38 / $585.65
CareSource
Facility/Professional
Professional
Modifier
Low / Median / High Price
$432.38 / $518.85 / $648.57
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
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$305.02 / $305.02 / $407.45