go back

South Dakota 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
$366.03 / $366.03 / $366.03
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$311.13 / $311.13 / $366.03
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$235.13 / $237.48 / $293.91
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$358.85 / $545.82 / $884.94
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$299.04 / $305.02 / $340.91
Midlands
Facility/Professional
Facility
Modifier
Low / Median / High Price
$444.38 / $444.38 / $518.44
Midlands
Facility/Professional
Professional
Modifier
Low / Median / High Price
$329.07 / $329.07 / $329.07
Sanford Health Plan
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 / $335.52
Wellmark
Facility/Professional
Facility
Modifier
Low / Median / High Price
$299.04 / $299.04 / $299.04
Wellmark
Facility/Professional
Professional
Modifier
Low / Median / High Price
$299.04 / $299.04 / $299.04