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Rhode Island 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
$1,189.59 / $1,189.59 / $1,189.59
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$292.82 / $303.80 / $311.13
BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$311.13 / $323.32 / $341.62
BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$329.43 / $329.43 / $329.43
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 / $336.16