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Texas rates for HCPCS A9515

Choline C-11 Diagnostic Per Study Dose Up To 20 Millicuries (Reinstated 01/01/2017) Supply Of Radiopharmaceutical Diagnostic Imaging Agent Technitium Tc-99m Pentetate Per Mci (Del 12/31/2005)

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$4,800.00 / $4,920.00 / $18,048.00
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$4,800.00 / $4,920.00 / $5,100.00
BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$4,980.00 / $12,748.80 / $25,149.00
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$5,100.00 / $5,100.00 / $5,100.00
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$5,100.00 / $5,100.00 / $5,100.00
Lucent Health
Facility/Professional
Facility
Modifier
Low / Median / High Price
$5,700.00 / $28,500.00 / $28,500.00
Lucent Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$22,800.00 / $22,800.00 / $27,000.00
Moda Health
Facility/Professional
Facility
Modifier
Low / Median / High Price
$4,920.00 / $6,000.00 / $10,707.00
Oscar Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$168.60 / $168.60 / $168.60
Providence
Facility/Professional
Facility
Modifier
Low / Median / High Price
$4,920.00 / $6,000.00 / $10,430.40
Providence
Facility/Professional
Professional
Modifier
Low / Median / High Price
$5,100.00 / $5,100.00 / $5,100.00
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$5,000.00 / $5,000.00 / $5,155.00
Wellpoint
Facility/Professional
Professional
Modifier
Low / Median / High Price
$5,000.00 / $5,700.00 / $7,695.00