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New Hampshire 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 / $366.02
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$311.13 / $311.13 / $311.13
Anthem BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$363.55 / $545.99 / $1,437.99
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$305.02 / $311.12 / $311.12
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
Harvard Pilgrim
Facility/Professional
Professional
Modifier
Low / Median / High Price
$311.13 / $422.27 / $873.37
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$305.02 / $305.02 / $732.05
Well Sense
Facility/Professional
Professional
Modifier
Low / Median / High Price
$271.63 / $317.26 / $2,500.00