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New Hampshire rates for HCPCS A9569

Technetium Tx-99m Exametazime Labeled Autologous White Blood Cells Diagnostic Per Study Dose

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,748.25 / $1,748.25 / $2,097.90
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
$1,472.16 / $3,085.15 / $4,719.31
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 / $2,651.40 / $5,395.97
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,713.97 / $1,713.97 / $1,748.25
Well Sense
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,559.34 / $1,715.27 / $2,183.08