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Maine 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
Professional
Modifier
Low / Median / High Price
$3,597.24 / $3,710.44 / $3,873.14
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,434.20 / $1,775.69 / $2,504.79
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$699.00 / $699.00 / $4,393.89
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$6,665.76 / $6,665.76 / $6,665.76
Harvard Pilgrim
Facility/Professional
Professional
Modifier
Low / Median / High Price
$91,862.50 / $91,862.50 / $91,862.50
Martin's Point
Facility/Professional
Professional
Modifier
Low / Median / High Price
$3,597.24 / $3,710.44 / $3,873.14
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$3,857.84 / $5,202.47 / $7,789.50