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Maine rates for HCPCS A9569

Technetium Tc-99m exametazime labeled autologous white blood cells, diagnostic, per study dose

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$2,840.66 / $2,840.66 / $2,840.66
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,748.25 / $1,748.25 / $1,748.25
Anthem BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,006.72 / $1,263.68 / $3,296.77
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,713.97 / $1,748.24 / $1,748.24
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,748.25 / $1,748.25 / $1,748.25
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,748.25 / $1,748.25 / $1,748.25
Harvard Pilgrim
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,748.25 / $1,748.25 / $2,094.58
Martin's Point
Facility/Professional
Facility
Modifier
Low / Median / High Price
$2,840.66 / $2,840.66 / $2,840.66
Martin's Point
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,748.25 / $1,748.25 / $1,748.25
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,713.97 / $1,713.97 / $2,570.96