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Maine rates for HCPCS A9521

Technetium Tc-99m exametazime, diagnostic, per study dose, up to 25 mCi

Insurance Carrier
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,659.59 / $1,737.80 / $1,737.80
Anthem BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$891.25 / $1,071.52 / $2,951.21
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,698.24 / $1,737.80 / $1,737.80
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$912.01 / $1,737.80 / $1,737.80
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,737.80 / $1,737.80 / $3,162.28
Harvard Pilgrim
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,737.80 / $1,737.80 / $2,089.30
Martin's Point
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,659.59 / $1,737.80 / $2,041.74
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,445.44 / $1,698.24 / $2,511.89