Radiopharmaceutical Fee Schedule - JE Part B
2023-2024 Radiopharmaceutical Fee Schedule
| 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 |
| 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 $1809.19 | $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 |
| 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 4/1/24 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 |
| 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 |
| A9572 | Indium 111- Pentetreotide (Octreoscan) | $6,470.64 | $6,470.64 |
| A9573 | Gadopiclenol, injection (Elucirem) | eff 10/1/23 $12.59 | $12.59 |
| 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 |
| 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 |
| A9607 | Pluvicto 1mci/ml | $242.25, eff 3/1/23 $247.10, eff 11/1/23 $259.45 | $259.45 |
| A9608 | Posluma (Flotufolastat F-18) 1 mci/ml | eff 1/1/24 $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 |
| Q9983 | Florbetaben F18, diagnostic, per study dose | $3,360.00 | $3,360.00 |
Last Updated Apr 12 , 2024
