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Michigan 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 / $373.20 / $99,703.50
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$292.82 / $292.82 / $292.82
BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$339.84 / $468.03 / $832.28
BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$298.49 / $326.77 / $424.17
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$249.39 / $311.13 / $311.13
Health Alliance Plan
Facility/Professional
Facility
Modifier
Low / Median / High Price
$323.32 / $502.39 / $99,703.50
Health Alliance Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$292.82 / $323.32 / $387.98
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$30.00 / $30.00 / $50.00
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$305.02 / $305.02 / $335.52