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
A9512 Technetium TC99-m Pertechnetate $1.78 $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