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Wisconsin rates for HCPCS A9576

Injection, gadoteridol, (ProHance multipack), per ml

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1.00 / $56.23 / $87.10
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1.00 / $1.00 / $1.00
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1.41 / $1.41 / $2.14
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1.41 / $3.09 / $5.37
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1.41 / $1.78 / $3.02
DeanCare
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1.32 / $1.41 / $2.88
DeanCare
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1.58 / $1.58 / $1.62
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1.32 / $2.88 / $19.05
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1.41 / $1.41 / $7.41
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1.41 / $50.12 / $85.11
Quartz
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1.41 / $1.48 / $4.37
Quartz
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1.41 / $1.41 / $100.00
Quartz
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1.41 / $1.74 / $7.41
Security Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1.86 / $1.86 / $2.29
United
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1.45 / $1.45 / $1.45
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1.41 / $1.41 / $2.14