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2008 Radiopharmaceutical Pricing

HCPCS Code Description JANUARY 2008 Old code Also Known As
A9500 Technetium TC99M Sestamibi/Cardiolite, Diagnostic, per study dose, up to 40 MCI $121.70 A9500 Cardiolite
A9501 Technetium TC-99m Teboroxime, Diagnostic, per study dose Invoice   add 1/1/2008
A9502 Technetium TC99M Tetrofosmin/Myoview, Diagnostic, per study dose , up to 40 MCI Effective July 1, 2008
$111.32

Prior to July 1, 2008
$117.85		 A9502  
A9503 Technetium TC99M Medronate/MPI MDP, Diagnostic, per study dose, up to 30 MCI $54.93 A9503 MDP
A9504 Technetium TC99M/Acutect/Apcitide Kit, Diagnostic, per study dose, up to 20 MCI $460.00 A9504  
A9505 Thallous Chloride TL 201, Diagnostic, per MCI $88.40 A9505  
A9507 Indium IN 111/Capromab Pendetide; Prostascint, Diagnostic, per study dose, up to 20 MCI $3,568.78 A9507 Prostascint
A9508 Iobenguane Sulfate I-131, Diagnostic, per .5 MCI $558.00 A9508  
A9509 Iodine I-123 Sodium Iodide, Diagnostic, per millicurie $88.57   add 1/1/2008
A9510 Technetium TC99M Disofenin/Hepatolite, Diagnostic, per study dose, up to 15 MCI $43.12 A9510 HEPATOLITE
A9512 Technetium TC99M Pertechnetate, Diagnostic, per MCI Invoice A9512 NATC04
A9516 I-123 Sodium Iodide Capsule(s), Diagnostic, per 100 microcuries $92.99 A9516  
A9517 I-131 Sodium Iodide Capsule(s), therapeutic, per MCI Invoice A9517  
A9521 Technetium TC99M Exametazine, Diagnostic, per study dose, up to 25 MCI $567.61 A9521 HMPAO, WBC, CERETEC
A9524 Iodinated I-131 Serum Albumin, Diagnostic, per 5 microcuries $59.09 A9524  
A9528 Iodine I-131 Sodium Iodide Capsule(s), Diagnostic, per MCI $40.38 A9528  
A9529 Iodine I-131 Sodium Iodide Solution, Diagnostic, per MCI Invoice A9529  
A9530 Iodine I-131 Sodium Iodide Solution, therapeutic, per MCI Invoice A9530  
A9531 Iodine I-131 Sodium Iodide, Diagnostic, per MCI (up to 100 MCI) Invoice A9531  
A9532 Iodine I-125 Serum Albumin, Diagnostic, per 5 microcuries Invoice A9532  
A9535 Methylene Blue, 1 cc $6.43 A9535  
A9536 Technetium TC 99M Depreotide, Diagnostic, per study does, up to 35 MCI $736.00 A9511  
A9537 Technetium TC 99M Mebrofenin, Diagnostic, per study dose, up to 15 MCI $63.06 A9513 CHOLETEC
A9538 Technetium TC 99M Pyrophosphate, Diagnostic, per study dose, up to 25 MCI $24.70 A9514 PYP
A9539 Technetium TC 99M Pentetate, Diagnostic, per study dose, up to 25 MCI $16.25 A9515 DTPA
A9540 Technetium TC 99M Macroaggregated Albumin, Diagnostic, per study dose, up to 10 MCI $21.53 A9519 MAA
A9541 Technetium TC 99M Sulfurcolloid, Diagnostic, per study dose, up to 20 MCI $53.20 A9520  
A9542 Indium IN-111 Ibritumomab Tiuxetan, Diagnostic, per study dose, up to 5 MCI $2,769.63 A9522  
A9543 Yttrium Y-90 Ibritumomab Tiuxetan, therapeutic, per treatment dose, up to 40 MCI Invoice A9523  
A9544 Iodine I-131 Tositumomab, Diagnostic, per study dose Invoice A9533  
A9545 Iodine I-131 Tositumomab, therapeutic, per treatment dose Invoice A9534  
A9546 Cobalt CO-57/58, Cyanocobalamin, Diagnostic, per study dose, up to 1 microcurie Invoice A9546  
A9547 Indium IN 111 Oxyquinoline, Diagnostic, per 0.5 MCI $414.00 A9547  
A9548 Indium IN 111 Pentetate, Diagnostic, per 0.5 MCI $248.40    
A9549 Technetium TC 99M Arcitumomab, Diagnostic, per study dose, up to 25 MCI $1,196.00 A9549  
A9550 Technetium TC 99M Sodium Gluceptate, Diagnostic, per study dose, up to 25 MCI Invoice Q3006  
A9551 Technetium TC 99M Succimer, Diagnostic, per study dose, up to 10 MCI $126.63 A9551  
A9552 Fluorodeoxyglucose F-18 FDG, Diagnostic, per study dose up to 45 MCI $240.00 A9552  
A9553 Chromium Cr-51 sodium chromate, Diagnostic, per study dose, up to 250 microcuries $371.89 A9553  
A9554 Iodine I-125 Sodium Iothalamate, Diagnostic, per study dose, up to 10 microcuries Invoice A9554  
A9555 Rubidium RB-82, Diagnostic, per study dose, up to 60 millicuries $250.00 A9555  
A9556 Gallium Ga-67Citrate, Diagnostic, per millicuire $32.04 Q3002 GALLIUM CITRATE
A9557 Technetium TC 99M Bicisate, Diagnostic, per study dose, up to 25 MCI Invoice Q3003  
A9558 Xenon Xe-133 gas, Diagnostic, per 10 MCI $38.96 Q3004 NAG 3/MAG 3
A9559 Cobalt CO-57 Cyanocobalamin, Oral, Diagnostic, per study dose up to 1microcurie Invoice Q3012  
A9560 Technetium TC 99M Labeled Red Blood Cells, Diagnostic, per study dose, up to 30 MCI $106.48 Q3010 ULTRATAG
A9561 Technetium TC 99M Oxidronate, Diagnostic, per study dose, up to 30 MCI $50.16 Q3009 HDP
A9562 Technetium TC 99M Mertiatide, Diagnostic, per study dose, up to 15 MCI $588.24 Q3005  
A9563 Sodium Phosphate P-32, therapeutic, per MCI $347.56 Q3007  
A9564 Chromic Phosphate P-32, suspension, therapeutic, per MCI $331.13 Q3011  
A9565 Indium In-111 Pentetreotide, Diagnostic, per MCI   Q3008 deleted 12/31/2007
A9566 Technetium TC 99M Fanolesomab, Diagnostic, per study dose up to 25 MCI Invoice A9566  
A9567 Technetium TC 99M Pentetate, Diagnostic, aerosol, per study dose, up to 75 MCI Invoice A9567  
A9569 Technetium TC-99m exametazime labeled autologous white blood cells, Diagnostic, Invoice   add 1/1/2008
A9570 Indium IN-111 labeled autologous white blood cells, Diagnostic, per study dose Invoice   add 1/1/2008
A9571 Indium IN-111 labeled autologous platelets, Diagnostic, per study dose Invoice   add 1/1/2008
A9572 Indium IN-111 Pentetreotide, Diagnostic, per study dose, up to 6 millicuries Invoice   add 1/1/2008
A9576 Injection, Gadoteridol, (Prohance Multipack), per ml $2.463   add 1/1/2008
A9577 Injection, Gadobenate Dimeglumine (Multihance), per ml $2.852   add 1/1/2008
A9578 Injection, Gadobenate Dimeglumine (Multihance Multipack), per ml $2.677   add 1/1/2008
A9579 Injection, Gadolinium-based magnetic resonance contrast agent, not otherwise $2.549   add 1/1/2008
A9600 Strontium Sr--89 Chloride/Metastron, therapeutic, per MCI $882.79 A9600  
A9605 Quadramet / Samarium Sm 153 Lexidronamm, therapeutic, per 50 MCI $1,692.99 A9605 quadramet
J1675 Histrelin 10 mg $1,140.00    
Q2004 Irrigation solution for treatment of bladder calculi, for example renacidin, per 500 mg $29.45    
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