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Virginia 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
$3,338.00 / $5,412.00 / $11,024.00
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$3,042.89 / $4,050.55 / $4,109.80
Anthem BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$8,525.00 / $11,065.00 / $12,418.00
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,110.78 / $1,403.11 / $1,948.13
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$490.00 / $4,393.89 / $10,570.23
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$6,665.76 / $6,665.76 / $6,665.76
Kaiser Permanente
Facility/Professional
Professional
Modifier
Low / Median / High Price
$3,662.40 / $4,444.70 / $5,481.80
Medcost
Facility/Professional
Facility
Modifier
Low / Median / High Price
$3,471.67 / $4,109.80 / $6,845.43
Sentara
Facility/Professional
Facility
Modifier
Low / Median / High Price
$3,704.17 / $4,815.30 / $8,210.58
Sentara
Facility/Professional
Professional
Modifier
Low / Median / High Price
$3,704.17 / $4,815.30 / $8,210.58
United
Facility/Professional
Facility
Modifier
Low / Median / High Price
$10,000.40 / $28,126.13 / $28,126.13
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$3,180.48 / $4,204.82 / $6,997.05