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California rates for HCPCS C9734

Focused Ultrasound Ablation/Therapeutic Inter- Vention Other Than Uterine Leiomyomata With Magnetic Resonance (Mr) Guidance(Revised 07012013)

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$27,789.86 / $27,789.86 / $27,789.86
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$11,399.57 / $11,399.57 / $11,399.57
Anthem BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$2,143.00 / $4,958.00 / $13,459.00
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$11.55 / $154.00 / $317.00
Blue Shield
Facility/Professional
Facility
Modifier
Low / Median / High Price
$92.60 / $9,972.28 / $39,433.00
Blue Shield
Facility/Professional
Professional
Modifier
Low / Median / High Price
$40.00 / $40.00 / $100.00
Contra Costa Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$9,300.16 / $9,300.16 / $9,765.17
Kaiser Permanente
Facility/Professional
Professional
Modifier
Low / Median / High Price
$393.93 / $393.93 / $393.93
Lucent Health
Facility/Professional
Facility
Modifier
Low / Median / High Price
$100.00 / $100.00 / $100.00
Providence
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,800,000.00 / $2,400,000.00 / $2,400,000.00
United
Facility/Professional
Facility
Modifier
Low / Median / High Price
$3,610.00 / $7,402.00 / $16,148.00