go back

Utah 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
$303.80 / $303.80 / $303.80
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$303.80 / $303.80 / $314.79
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$311.13 / $311.13 / $311.13
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$45.00 / $45.00 / $60.00
Regence BlueShield
Facility/Professional
Facility
Modifier
Low / Median / High Price
$456.61 / $596.99 / $857.07
Regence BlueShield
Facility/Professional
Professional
Modifier
Low / Median / High Price
$347.73 / $428.47 / $451.01
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$305.02 / $305.02 / $305.02