Radiopharmaceutical - JE Part B
Radiopharmaceutical Fee Schedule
The inclusion of a fee amount does not warrant coverage. Payment limits are subject to change annually. Invoices can be used to establish fees. If you have invoice information, you can submit invoices in advance to the following address. Invoices can be used to establish fees in conjunction with or without Average Wholesale Pricing (AWP) information.
| Procedure Code |
Description | 2023 | 2024 |
|---|---|---|---|
| A4648 | Tissue Marker, each | priced per invoice | priced per invoice |
| A9500 | Technetium TC99- Sestamibi (Cardiolite, MIBI, Miraluma) | priced per invoice | priced per invoice |
| A9502 | Tc99m Tetrofosmin | $97.21 | $97.21 |
| A9503 | Technetium TC99-m Medronate (MDP, Osteolite) | $14.82 | $14.82 |
| A9505 | Thallous Chloride TL-201 | $154.44, eff 2/1/23 $37.23 | $37.23 |
| A9507 | Indium IN-111 Capromab Pendetide (Proctascint) | $835.24 | $835.24 |
| A9509 | Iodine I 123 Sodium Iodide, diagnostic | $204.90 | $204.90 |
| A9510 | Technetium TC99-m Disofenin (Hepatolite) | $79.80 | $79.80 |
| A9512 | Technetium TC99-m Pertechnetate | $1.78 | eff 1/1/24-2/29/24 - $1.90, 3/1/24-3/31/24 - $1.93, 4/1/24 -$1.90 |
| A9513 | Lutetium lu 177, dotatate, therapeutic | effective 3/1/23 $312.36, eff 11/1/23 $318.61 | $318.61, eff 7/1/24 $334.53 |
| A9515 | Choline C-11, diagnostic | $5,700.00 | $5,700.00 |
| A9516 | I-123 Sodium Iodide Capsule 100 UCI (Diagnostic) | priced per invoice | priced per invoice |
| A9517 | I - 131 Sodium Iodide Capsule (Therapeutic) | $40.70 | $40.70 |
| A9520 | Technetium Tc 99m tilmanocept, diagnostic | $535.57, eff 6/1/23 $754.20 | $754.20 |
| A9521 | Tc99-m Exametazine (Ceretec)(HMPOA) | $1742.79, eff 6/1/23 $1,809.19 | $1,809.19, eff 2/1/24 $1,953.92 |
| A9524 | Iodine I-131 iodinated serum | $536.75 for 25 mCi, eff 3/1/23 $590.43 per 25 mCi | $705.44 per 25 mCi |
| A9526 | Ammonia N- 13 | $751.26 | $751.26 |
| A9527 | Iodine I-125 Sodium Iodinr solution, therapeutic, per mCi | priced per invoice | priced per invoice |
| A9528 | I - 131 Sodium Iodide Capsule diagnostic | priced per invoice | priced per invoice |
| A9529 | I - 131 Sodium Iodide solution diagnostic | priced per invoice | priced per invoice |
| A9530 | I - 131 Sodium Iodide solution therapeutic | priced per invoice | priced per invoice |
| A9531 | I - 131 Sodium Iodide diagnostic | priced per invoice | priced per invoice |
| A9537 | Technetium tc 99m Mebrofenin (Choletec) | $63.06 | $63.06 |
| A9538 | Technetium tc 99m Pyrophosphate | $73.02 | $73.02 |
| A9539 | Technetium tc 99m Pentetate (An-DTPA) | $35.72 | $35.72 |
| A9540 | Tc-99m Macro (MAA) (Pulmolite) | $34.20 | $34.20 |
| A9541 | Technetium TC-99m sulfur collid | $304.80 | $304.80 |
| A9542 | Indium - 111 Ibritumomabituxetan diagnostic (Zevalin) | $3,990.00 | $3,990.00 |
| A9543 | Yttrium 90 Ibritumomab Tiuxetan therapeutic (Zevalin) | $70,418.21 | $70,418.21 |
| A9547 | Indium IN-111 Oxyquinoline (Oxine, Indium-111 WBC) | $2,221.93, eff 7/1/23 $2,038.46 | $2,201.54, eff 7/1/24 $2,399.68 |
| A9548 | Indiuim IN-111 Pentetate (Indium DTPA or Indium 111 DTPA) | $890.19 | $961.40 |
| A9551 | TC-99 Succime (DMSA) | $683.33 | $683.33 |
| A9552 | Fluorodexy Glucose (FDG); F-18 NAF Fluorine-18 | $250.00 - *Effective 10/1/17 AK price at $400, HI $551.50, other states price at $250.00 thru 2/28/21. Effective 3/1/21 price states other than AK, HI at $359.05 | $250.00 - *Effective 10/1/17 AK price at $400, HI $551.50, other states price at $250.00 thru 2/28/21. Effective 3/1/21 price states other than AK, HI at $359.05. Effective 1/1/24 price HI at $738.28 |
| A9554 | Na Iotholamate I-125 (Glofil) | $39.90, eff 7/1/23 $42.75 | $42.75 |
| A9555 | Rubidium 82 (Cardiogen-82 Generator) | $520.75 | $520.75 |
| A9556 | Gallium Citrate Ga-67 Diagnostic | $153.92 | $153.92 |
| A9557 | Technetium TC99-m Bicisate (Neurolite) | $424.18, eff 2/1/23 $3,722.82 | Eff 1/1/24 $4,057.88 |
| A9558 | Xenon-Xe-133 | $263.78 | $276.96 |
| A9560 | Technetium TC99-m Labeled Red Blood Cell (Ultratag RBC) | $106.48 | $106.48 |
| A9561 | Technetium Tc 99m Oxidronate (HDP) | $50.16 | $50.16 |
| A9562 | Technetium Tc 99m Mertiatide (MAG 3) | $883.24 | $883.24 |
| A9563 | Sodium Phosphate P32- diagnostic | $347.56 | $347.56 |
| A9564 | Chromic Phosphate 32 suspension - diagnostic (Phosphocol) | $331.13 | $331.13 |
| A9567 | Technetium TC- 99m Pentetate diagnostic | priced per invoice | priced per invoice |
| A9568 | Technetium TC -99m Arcitumomab, diagnostic, per study dose | $1,235.00 | $1,235.00 |
| A9569 | Technetium Tc 99m Fanolesomab diagnostic | $1,742.79, eff 6/1/23 $1,809.19 | $1,809.19, eff 2/1/24 $1,953.92 |
| A9570 | Indium in-111, labeled autologous white blood cells, diagnostic, per study dose | Effective 1/1/23 $4,443.84, eff 7/1/23 $4,076.93 | Eff 1/1/24 $4,403.08, eff 7/1/24 $4,799.35 |
| A9571 | Indium in-111, labeled autologous platelets, diagnostic, per study dose | Effective 1/1/23 $4,443.84, eff 7/1/23 $4,076.93 | Eff 1/1/24 $4,403.08, eff 7/1/24 $4,799.35 |
| A9572 | Indium 111- Pentetreotide (Octreoscan) | $6,470.64 | $6,470.64 |
| A9573 | Gadopiclenol, injection (Elucirem) | Effective 10/1/23 $12.59 | 1/1/24-3/31/24 $12.59, eff 4/1/24 CMS priced |
| A9582 | Iodine I-123 iobenguane, diagnostic, per study dose (AdreView) | Effective 1/1/23 $5,135.43 | Effective 1/1/24 $5,546.27 |
| A9584 | Iodine 1-123 ioflupane (Datscan) | $2,813.52 | $2,813.52 |
| A9586 | Florbetapir F-18 | $3,257.44 | $3,257.44 |
| A9587 | Gallium Ga-68 diagnostic | $73.89, effective 2/1/22 $63.34 | $63.34 |
| A9588 | Fluciclovine F-18 diagnostic | $547.20 | $547.20, eff 2/1/24 $563.42 |
| A9591 | Fluoroestradiol F-18 diagnostic | Effective 1/1/23 $762.85, eff 7/1/23 $797.49 | Effective 1/1/24 $836.00 |
| A9592 | DetectNET (Copper Cu64 Dotatate) | $1054.50 eff 4/1/23 $1,097.25 | $1,097.25 |
| A9593 | Gallium ga-68 psma-11, diagnostic, (ucsf) | priced per invoice | priced per invoice |
| A9594 | Gallium ga-68 psma-11, diagnostic, (ucla) | priced per invoice | priced per invoice |
| A9595 | Pylarify® (Piflufolastat F 18) | Effective 1/1/23 $600.14, effective 2/1/23 $624.15 | Effective 1/1/24 $661.54 |
| A9596 | Illuccix® (Gallium 68-ga Gozetotide/PSMA-11) | $1,071.60 | $1,121.76 |
| A9597 | Posluma (Flotufolastat F-18) | Eff 5/25/23-12/31/23 $680.44 | NA |
| A9600 | Strontium-89 Chloride (Metastron) | $4,275.00 | $4,275.00 |
| A9602 | Fluorodopa F 18 Per mCi, up to 5 UOS | $578.71 per mci | $578.71 per mci |
| A9604 | Samarium sm-153 Lexidronam (Quadramet) | $18,562.49 | $18,562.49 |
| A9606 | Xofigo Radium 223 | 1/1/23-1/31/23 $171.16, 2/1/23 $174.58 | $174.58, eff 2/1/24 $181.62, eff 8/1/24 $187.07 |
| A9607 | Pluvicto 1mci/ml | $242.25, eff 3/1/23 $247.10, eff 11/1/23 $259.45 | $259.45, eff 7/1/24 $271.12 |
| A9608 | Posluma (Flotufolastat F-18) | NA | eff 1/1/24-1/31/24 $680.44, eff 2/1/24 $700.85 |
| A9698 | Iohexol (Omnipague) 9 mg/ml | $11.51 | $11.51 |
| A9800 | Locametz™ (Gallium 68-ga Gozetotide, diagnostic, per mCi) | $912.00, eff 3/1/23 $939.36 | $939.36 |
| Q9962 | High Osmolor Contrast Material 300-349 mg/ml | $0.18 | $0.18 |
| Q9982 | Flutemetamol F18, diagnostic, per study dose | $3,960.00 | $3,960.00, eff 7/1/24 $3,648.00 |
| Q9983 | Florbetaben F18, diagnostic, per study dose | $3,360.00, eff 11/1/23 $3,876.00 | $3,876.00 |
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