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South Carolina 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
$300.14 / $62,799.18 / $100,595.60
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$279.48 / $300.14 / $303.80
BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$183.10 / $312.49 / $505.92
BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$322.11 / $366.03 / $453.95
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
Medcost
Facility/Professional
Facility
Modifier
Low / Median / High Price
$300.14 / $358.85 / $405.19
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$30.00 / $30.00 / $30.00
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$305.02 / $305.02 / $305.02