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Montana rates for HCPCS A9576

Injection, gadoteridol, (ProHance multipack), per ml

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$99.21 / $140.86 / $187.86
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1.41 / $1.42 / $2.12
BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$4.94 / $77,999.99 / $94,999.99
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1.63 / $1.63 / $4.16
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1.41 / $1.41 / $1.63
Providence
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1.63 / $1.63 / $4.16
Providence
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1.53 / $1.53 / $1.76
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1.42 / $1.42 / $1.42