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Utah 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
$4,980.00 / $4,980.00 / $4,980.00
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$4,980.00 / $4,980.00 / $5,160.00
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$5,100.00 / $5,100.00 / $5,100.00
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$45.00 / $45.00 / $60.00
Regence BlueShield
Facility/Professional
Professional
Modifier
Low / Median / High Price
$5,700.00 / $7,023.54 / $7,392.90
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$5,000.00 / $5,000.00 / $5,000.00