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Idaho rates for HCPCS 0686T

Histotripsy (ie, non-thermal ablation via acoustic energy delivery) of malignant hepatocellular tissue, including image guidance

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$3,422.00 / $4,500.00 / $8,622.00
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$2,546.15 / $3,549.42 / $4,328.20
Moda Health
Facility/Professional
Facility
Modifier
Low / Median / High Price
$2,017.44 / $3,633.47 / $5,175.10
Moda Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$874.22 / $874.22 / $874.22
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$30.00 / $3,500.00 / $5,711.95
Regence BlueShield
Facility/Professional
Facility
Modifier
Low / Median / High Price
$26,576.06 / $35,001.00 / $55,651.59
Regence BlueShield
Facility/Professional
Professional
Modifier
Low / Median / High Price
$4,782.20 / $4,782.20 / $4,782.20
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$4,020.52 / $4,262.89 / $7,246.93