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Utah rates for HCPCS A9576

Injection, gadoteridol, (ProHance multipack), per ml

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$77.62 / $812.83 / $933.25
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1.00 / $1.00 / $1.00
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1.66 / $2.24 / $2.24
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1.41 / $1.41 / $1.41
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$2.04 / $2.24 / $60.26
Regence BlueShield
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1.41 / $1.41 / $1.91
Select Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1.48 / $1.55 / $2.19
U of Utah Health Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1.29 / $1.41 / $1.70
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1.41 / $1.41 / $1.41