|
PRO FEE ER APPL OF LONG LEG SPLINT
|
Professional
|
Both
|
$90.00
|
|
|
Service Code
|
HCPCS 29505
|
| Hospital Charge Code |
7229505
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$63.00 |
| Max. Negotiated Rate |
$90.00 |
| Rate for Payer: Aetna Commercial |
$85.50
|
| Rate for Payer: Aetna Medicare |
$81.00
|
| Rate for Payer: BCBS MT CHIP |
$81.00
|
| Rate for Payer: BCBS MT Closed Plan Network |
$85.50
|
| Rate for Payer: BCBS MT HealthLink |
$81.00
|
| Rate for Payer: BCBS MT Medicare |
$81.00
|
| Rate for Payer: BCBS MT POS |
$85.50
|
| Rate for Payer: BCBS MT Traditional |
$90.00
|
| Rate for Payer: Cash Price |
$81.00
|
| Rate for Payer: Cigna Commercial |
$85.50
|
| Rate for Payer: Cigna Medicare |
$81.00
|
| Rate for Payer: Medicaid All Medicaid |
$82.80
|
| Rate for Payer: Medicare All Medicare |
$63.00
|
| Rate for Payer: Monida Allegiance |
$85.50
|
| Rate for Payer: Monida First Choice Health |
$87.30
|
| Rate for Payer: Monida Montana Health Co-op |
$85.50
|
| Rate for Payer: Monida PacificSource |
$85.50
|
|
|
PRO FEE ER BRIEF 99281
|
Professional
|
Both
|
$85.00
|
|
|
Service Code
|
HCPCS 99281 AQ
|
| Hospital Charge Code |
799281
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$59.50 |
| Max. Negotiated Rate |
$85.00 |
| Rate for Payer: Aetna Commercial |
$80.75
|
| Rate for Payer: Aetna Medicare |
$76.50
|
| Rate for Payer: BCBS MT CHIP |
$76.50
|
| Rate for Payer: BCBS MT Closed Plan Network |
$80.75
|
| Rate for Payer: BCBS MT HealthLink |
$76.50
|
| Rate for Payer: BCBS MT Medicare |
$76.50
|
| Rate for Payer: BCBS MT POS |
$80.75
|
| Rate for Payer: BCBS MT Traditional |
$85.00
|
| Rate for Payer: Cash Price |
$76.50
|
| Rate for Payer: Cigna Commercial |
$80.75
|
| Rate for Payer: Cigna Medicare |
$76.50
|
| Rate for Payer: Medicaid All Medicaid |
$78.20
|
| Rate for Payer: Medicare All Medicare |
$59.50
|
| Rate for Payer: Monida Allegiance |
$80.75
|
| Rate for Payer: Monida First Choice Health |
$82.45
|
| Rate for Payer: Monida Montana Health Co-op |
$80.75
|
| Rate for Payer: Monida PacificSource |
$80.75
|
|
|
PRO FEE ER CLOSED TRT NOSE FX W/O STAB
|
Professional
|
Both
|
$137.00
|
|
|
Service Code
|
HCPCS 21315
|
| Hospital Charge Code |
721315
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$95.90 |
| Max. Negotiated Rate |
$137.00 |
| Rate for Payer: Aetna Commercial |
$130.15
|
| Rate for Payer: Aetna Medicare |
$123.30
|
| Rate for Payer: BCBS MT CHIP |
$123.30
|
| Rate for Payer: BCBS MT Closed Plan Network |
$130.15
|
| Rate for Payer: BCBS MT HealthLink |
$123.30
|
| Rate for Payer: BCBS MT Medicare |
$123.30
|
| Rate for Payer: BCBS MT POS |
$130.15
|
| Rate for Payer: BCBS MT Traditional |
$137.00
|
| Rate for Payer: Cash Price |
$123.30
|
| Rate for Payer: Cigna Commercial |
$130.15
|
| Rate for Payer: Cigna Medicare |
$123.30
|
| Rate for Payer: Medicaid All Medicaid |
$126.04
|
| Rate for Payer: Medicare All Medicare |
$95.90
|
| Rate for Payer: Monida Allegiance |
$130.15
|
| Rate for Payer: Monida First Choice Health |
$132.89
|
| Rate for Payer: Monida Montana Health Co-op |
$130.15
|
| Rate for Payer: Monida PacificSource |
$130.15
|
|
|
PRO FEE ER COMPREHENSIVE 99285
|
Professional
|
Both
|
$385.00
|
|
|
Service Code
|
HCPCS 99285 AQ
|
| Hospital Charge Code |
799285
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$269.50 |
| Max. Negotiated Rate |
$385.00 |
| Rate for Payer: Aetna Commercial |
$365.75
|
| Rate for Payer: Aetna Medicare |
$346.50
|
| Rate for Payer: BCBS MT CHIP |
$346.50
|
| Rate for Payer: BCBS MT Closed Plan Network |
$365.75
|
| Rate for Payer: BCBS MT HealthLink |
$346.50
|
| Rate for Payer: BCBS MT Medicare |
$346.50
|
| Rate for Payer: BCBS MT POS |
$365.75
|
| Rate for Payer: BCBS MT Traditional |
$385.00
|
| Rate for Payer: Cash Price |
$346.50
|
| Rate for Payer: Cigna Commercial |
$365.75
|
| Rate for Payer: Cigna Medicare |
$346.50
|
| Rate for Payer: Medicaid All Medicaid |
$354.20
|
| Rate for Payer: Medicare All Medicare |
$269.50
|
| Rate for Payer: Monida Allegiance |
$365.75
|
| Rate for Payer: Monida First Choice Health |
$373.45
|
| Rate for Payer: Monida Montana Health Co-op |
$365.75
|
| Rate for Payer: Monida PacificSource |
$365.75
|
|
|
PRO FEE ER CRITICAL CARE 1HR 99291
|
Professional
|
Both
|
$572.00
|
|
|
Service Code
|
HCPCS 99291 AQ
|
| Hospital Charge Code |
799291
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$400.40 |
| Max. Negotiated Rate |
$572.00 |
| Rate for Payer: Aetna Commercial |
$543.40
|
| Rate for Payer: Aetna Medicare |
$514.80
|
| Rate for Payer: BCBS MT CHIP |
$514.80
|
| Rate for Payer: BCBS MT Closed Plan Network |
$543.40
|
| Rate for Payer: BCBS MT HealthLink |
$514.80
|
| Rate for Payer: BCBS MT Medicare |
$514.80
|
| Rate for Payer: BCBS MT POS |
$543.40
|
| Rate for Payer: BCBS MT Traditional |
$572.00
|
| Rate for Payer: Cash Price |
$514.80
|
| Rate for Payer: Cigna Commercial |
$543.40
|
| Rate for Payer: Cigna Medicare |
$514.80
|
| Rate for Payer: Medicaid All Medicaid |
$526.24
|
| Rate for Payer: Medicare All Medicare |
$400.40
|
| Rate for Payer: Monida Allegiance |
$543.40
|
| Rate for Payer: Monida First Choice Health |
$554.84
|
| Rate for Payer: Monida Montana Health Co-op |
$543.40
|
| Rate for Payer: Monida PacificSource |
$543.40
|
|
|
PRO FEE ER CRITICAL CARE E ADD 30m 99292
|
Professional
|
Both
|
$257.00
|
|
|
Service Code
|
HCPCS 99292 AQ
|
| Hospital Charge Code |
799292
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$179.90 |
| Max. Negotiated Rate |
$257.00 |
| Rate for Payer: Aetna Commercial |
$244.15
|
| Rate for Payer: Aetna Medicare |
$231.30
|
| Rate for Payer: BCBS MT CHIP |
$231.30
|
| Rate for Payer: BCBS MT Closed Plan Network |
$244.15
|
| Rate for Payer: BCBS MT HealthLink |
$231.30
|
| Rate for Payer: BCBS MT Medicare |
$231.30
|
| Rate for Payer: BCBS MT POS |
$244.15
|
| Rate for Payer: BCBS MT Traditional |
$257.00
|
| Rate for Payer: Cash Price |
$231.30
|
| Rate for Payer: Cigna Commercial |
$244.15
|
| Rate for Payer: Cigna Medicare |
$231.30
|
| Rate for Payer: Medicaid All Medicaid |
$236.44
|
| Rate for Payer: Medicare All Medicare |
$179.90
|
| Rate for Payer: Monida Allegiance |
$244.15
|
| Rate for Payer: Monida First Choice Health |
$249.29
|
| Rate for Payer: Monida Montana Health Co-op |
$244.15
|
| Rate for Payer: Monida PacificSource |
$244.15
|
|
|
PRO FEE ER EXTENDED 99284
|
Professional
|
Both
|
$261.00
|
|
|
Service Code
|
HCPCS 99284 AQ
|
| Hospital Charge Code |
799284
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$182.70 |
| Max. Negotiated Rate |
$261.00 |
| Rate for Payer: Aetna Commercial |
$247.95
|
| Rate for Payer: Aetna Medicare |
$234.90
|
| Rate for Payer: BCBS MT CHIP |
$234.90
|
| Rate for Payer: BCBS MT Closed Plan Network |
$247.95
|
| Rate for Payer: BCBS MT HealthLink |
$234.90
|
| Rate for Payer: BCBS MT Medicare |
$234.90
|
| Rate for Payer: BCBS MT POS |
$247.95
|
| Rate for Payer: BCBS MT Traditional |
$261.00
|
| Rate for Payer: Cash Price |
$234.90
|
| Rate for Payer: Cigna Commercial |
$247.95
|
| Rate for Payer: Cigna Medicare |
$234.90
|
| Rate for Payer: Medicaid All Medicaid |
$240.12
|
| Rate for Payer: Medicare All Medicare |
$182.70
|
| Rate for Payer: Monida Allegiance |
$247.95
|
| Rate for Payer: Monida First Choice Health |
$253.17
|
| Rate for Payer: Monida Montana Health Co-op |
$247.95
|
| Rate for Payer: Monida PacificSource |
$247.95
|
|
|
PRO FEE ER INTERMEDIATE 99283
|
Professional
|
Both
|
$139.00
|
|
|
Service Code
|
HCPCS 99283 AQ
|
| Hospital Charge Code |
799283
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$97.30 |
| Max. Negotiated Rate |
$139.00 |
| Rate for Payer: Aetna Commercial |
$132.05
|
| Rate for Payer: Aetna Medicare |
$125.10
|
| Rate for Payer: BCBS MT CHIP |
$125.10
|
| Rate for Payer: BCBS MT Closed Plan Network |
$132.05
|
| Rate for Payer: BCBS MT HealthLink |
$125.10
|
| Rate for Payer: BCBS MT Medicare |
$125.10
|
| Rate for Payer: BCBS MT POS |
$132.05
|
| Rate for Payer: BCBS MT Traditional |
$139.00
|
| Rate for Payer: Cash Price |
$125.10
|
| Rate for Payer: Cigna Commercial |
$132.05
|
| Rate for Payer: Cigna Medicare |
$125.10
|
| Rate for Payer: Medicaid All Medicaid |
$127.88
|
| Rate for Payer: Medicare All Medicare |
$97.30
|
| Rate for Payer: Monida Allegiance |
$132.05
|
| Rate for Payer: Monida First Choice Health |
$134.83
|
| Rate for Payer: Monida Montana Health Co-op |
$132.05
|
| Rate for Payer: Monida PacificSource |
$132.05
|
|
|
PRO FEE ER LIMITED 99282
|
Professional
|
Both
|
$95.00
|
|
|
Service Code
|
HCPCS 99282 AQ
|
| Hospital Charge Code |
799282
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$66.50 |
| Max. Negotiated Rate |
$95.00 |
| Rate for Payer: Aetna Commercial |
$90.25
|
| Rate for Payer: Aetna Medicare |
$85.50
|
| Rate for Payer: BCBS MT CHIP |
$85.50
|
| Rate for Payer: BCBS MT Closed Plan Network |
$90.25
|
| Rate for Payer: BCBS MT HealthLink |
$85.50
|
| Rate for Payer: BCBS MT Medicare |
$85.50
|
| Rate for Payer: BCBS MT POS |
$90.25
|
| Rate for Payer: BCBS MT Traditional |
$95.00
|
| Rate for Payer: Cash Price |
$85.50
|
| Rate for Payer: Cigna Commercial |
$90.25
|
| Rate for Payer: Cigna Medicare |
$85.50
|
| Rate for Payer: Medicaid All Medicaid |
$87.40
|
| Rate for Payer: Medicare All Medicare |
$66.50
|
| Rate for Payer: Monida Allegiance |
$90.25
|
| Rate for Payer: Monida First Choice Health |
$92.15
|
| Rate for Payer: Monida Montana Health Co-op |
$90.25
|
| Rate for Payer: Monida PacificSource |
$90.25
|
|
|
PRO FEE ER OP INJ TRIGEM NRV BLC 64400
|
Professional
|
Both
|
$149.00
|
|
|
Service Code
|
HCPCS 64400
|
| Hospital Charge Code |
764401
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$104.30 |
| Max. Negotiated Rate |
$149.00 |
| Rate for Payer: Aetna Commercial |
$141.55
|
| Rate for Payer: Aetna Medicare |
$134.10
|
| Rate for Payer: BCBS MT CHIP |
$134.10
|
| Rate for Payer: BCBS MT Closed Plan Network |
$141.55
|
| Rate for Payer: BCBS MT HealthLink |
$134.10
|
| Rate for Payer: BCBS MT Medicare |
$134.10
|
| Rate for Payer: BCBS MT POS |
$141.55
|
| Rate for Payer: BCBS MT Traditional |
$149.00
|
| Rate for Payer: Cash Price |
$134.10
|
| Rate for Payer: Cigna Commercial |
$141.55
|
| Rate for Payer: Cigna Medicare |
$134.10
|
| Rate for Payer: Medicaid All Medicaid |
$137.08
|
| Rate for Payer: Medicare All Medicare |
$104.30
|
| Rate for Payer: Monida Allegiance |
$141.55
|
| Rate for Payer: Monida First Choice Health |
$144.53
|
| Rate for Payer: Monida Montana Health Co-op |
$141.55
|
| Rate for Payer: Monida PacificSource |
$141.55
|
|
|
PRO FEE ER STRAPPING OF WRIST
|
Professional
|
Both
|
$56.00
|
|
|
Service Code
|
HCPCS 29260
|
| Hospital Charge Code |
729260
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$39.20 |
| Max. Negotiated Rate |
$56.00 |
| Rate for Payer: Aetna Commercial |
$53.20
|
| Rate for Payer: Aetna Medicare |
$50.40
|
| Rate for Payer: BCBS MT CHIP |
$50.40
|
| Rate for Payer: BCBS MT Closed Plan Network |
$53.20
|
| Rate for Payer: BCBS MT HealthLink |
$50.40
|
| Rate for Payer: BCBS MT Medicare |
$50.40
|
| Rate for Payer: BCBS MT POS |
$53.20
|
| Rate for Payer: BCBS MT Traditional |
$56.00
|
| Rate for Payer: Cash Price |
$50.40
|
| Rate for Payer: Cigna Commercial |
$53.20
|
| Rate for Payer: Cigna Medicare |
$50.40
|
| Rate for Payer: Medicaid All Medicaid |
$51.52
|
| Rate for Payer: Medicare All Medicare |
$39.20
|
| Rate for Payer: Monida Allegiance |
$53.20
|
| Rate for Payer: Monida First Choice Health |
$54.32
|
| Rate for Payer: Monida Montana Health Co-op |
$53.20
|
| Rate for Payer: Monida PacificSource |
$53.20
|
|
|
PRO FEE EXC MALIGNANT LESION INC MARGINS
|
Professional
|
Both
|
$179.00
|
|
|
Service Code
|
HCPCS 11602 AQ
|
| Hospital Charge Code |
711602
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$125.30 |
| Max. Negotiated Rate |
$173.63 |
| Rate for Payer: Aetna Commercial |
$170.05
|
| Rate for Payer: Aetna Medicare |
$161.10
|
| Rate for Payer: Cash Price |
$161.10
|
| Rate for Payer: Medicaid All Medicaid |
$164.68
|
| Rate for Payer: Medicare All Medicare |
$125.30
|
| Rate for Payer: Monida Allegiance |
$170.05
|
| Rate for Payer: Monida First Choice Health |
$173.63
|
| Rate for Payer: Monida Montana Health Co-op |
$170.05
|
| Rate for Payer: Monida PacificSource |
$170.05
|
|
|
PRO FEE FOREIGN BODY REMOVAL-EAR 69200
|
Professional
|
Both
|
$63.00
|
|
|
Service Code
|
HCPCS 69200 AQ
|
| Hospital Charge Code |
769200
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$44.10 |
| Max. Negotiated Rate |
$63.00 |
| Rate for Payer: Aetna Commercial |
$59.85
|
| Rate for Payer: Aetna Medicare |
$56.70
|
| Rate for Payer: BCBS MT CHIP |
$56.70
|
| Rate for Payer: BCBS MT Closed Plan Network |
$59.85
|
| Rate for Payer: BCBS MT HealthLink |
$56.70
|
| Rate for Payer: BCBS MT Medicare |
$56.70
|
| Rate for Payer: BCBS MT POS |
$59.85
|
| Rate for Payer: BCBS MT Traditional |
$63.00
|
| Rate for Payer: Cash Price |
$56.70
|
| Rate for Payer: Cigna Commercial |
$59.85
|
| Rate for Payer: Cigna Medicare |
$56.70
|
| Rate for Payer: Medicaid All Medicaid |
$57.96
|
| Rate for Payer: Medicare All Medicare |
$44.10
|
| Rate for Payer: Monida Allegiance |
$59.85
|
| Rate for Payer: Monida First Choice Health |
$61.11
|
| Rate for Payer: Monida Montana Health Co-op |
$59.85
|
| Rate for Payer: Monida PacificSource |
$59.85
|
|
|
PRO FEE I&D ABCESS/CYST SIMPLE
|
Professional
|
Both
|
$120.00
|
|
|
Service Code
|
HCPCS 10060
|
| Hospital Charge Code |
710060
|
|
Hospital Revenue Code
|
969
|
| Min. Negotiated Rate |
$84.00 |
| Max. Negotiated Rate |
$116.40 |
| Rate for Payer: Aetna Commercial |
$114.00
|
| Rate for Payer: Aetna Medicare |
$108.00
|
| Rate for Payer: Cash Price |
$108.00
|
| Rate for Payer: Medicaid All Medicaid |
$110.40
|
| Rate for Payer: Medicare All Medicare |
$84.00
|
| Rate for Payer: Monida Allegiance |
$114.00
|
| Rate for Payer: Monida First Choice Health |
$116.40
|
| Rate for Payer: Monida Montana Health Co-op |
$114.00
|
| Rate for Payer: Monida PacificSource |
$114.00
|
|
|
PRO FEE INC&REMOVAL FOREIGN BODY-SIMPLE
|
Professional
|
Both
|
$153.00
|
|
|
Service Code
|
HCPCS 10120
|
| Hospital Charge Code |
710120
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$107.10 |
| Max. Negotiated Rate |
$153.00 |
| Rate for Payer: Aetna Commercial |
$145.35
|
| Rate for Payer: Aetna Medicare |
$137.70
|
| Rate for Payer: BCBS MT CHIP |
$137.70
|
| Rate for Payer: BCBS MT Closed Plan Network |
$145.35
|
| Rate for Payer: BCBS MT HealthLink |
$137.70
|
| Rate for Payer: BCBS MT Medicare |
$137.70
|
| Rate for Payer: BCBS MT POS |
$145.35
|
| Rate for Payer: BCBS MT Traditional |
$153.00
|
| Rate for Payer: Cash Price |
$137.70
|
| Rate for Payer: Cigna Commercial |
$145.35
|
| Rate for Payer: Cigna Medicare |
$137.70
|
| Rate for Payer: Medicaid All Medicaid |
$140.76
|
| Rate for Payer: Medicare All Medicare |
$107.10
|
| Rate for Payer: Monida Allegiance |
$145.35
|
| Rate for Payer: Monida First Choice Health |
$148.41
|
| Rate for Payer: Monida Montana Health Co-op |
$145.35
|
| Rate for Payer: Monida PacificSource |
$145.35
|
|
|
PROFEE INJ ASPIR JOINT INJ INTERM 20605
|
Professional
|
Both
|
$317.00
|
|
|
Service Code
|
HCPCS 20605
|
| Hospital Charge Code |
7620605
|
|
Hospital Revenue Code
|
964
|
| Min. Negotiated Rate |
$221.90 |
| Max. Negotiated Rate |
$317.00 |
| Rate for Payer: Aetna Commercial |
$301.15
|
| Rate for Payer: Aetna Medicare |
$285.30
|
| Rate for Payer: BCBS MT CHIP |
$285.30
|
| Rate for Payer: BCBS MT Closed Plan Network |
$301.15
|
| Rate for Payer: BCBS MT HealthLink |
$285.30
|
| Rate for Payer: BCBS MT Medicare |
$285.30
|
| Rate for Payer: BCBS MT POS |
$301.15
|
| Rate for Payer: BCBS MT Traditional |
$317.00
|
| Rate for Payer: Cash Price |
$285.30
|
| Rate for Payer: Cigna Commercial |
$301.15
|
| Rate for Payer: Cigna Medicare |
$285.30
|
| Rate for Payer: Medicaid All Medicaid |
$291.64
|
| Rate for Payer: Medicare All Medicare |
$221.90
|
| Rate for Payer: Monida Allegiance |
$301.15
|
| Rate for Payer: Monida First Choice Health |
$307.49
|
| Rate for Payer: Monida Montana Health Co-op |
$301.15
|
| Rate for Payer: Monida PacificSource |
$301.15
|
|
|
PRO FEE INJECTION, THERAPEUTIC CARPAL TN
|
Professional
|
Both
|
$74.00
|
|
|
Service Code
|
HCPCS 20526
|
| Hospital Charge Code |
720526
|
|
Hospital Revenue Code
|
964
|
| Min. Negotiated Rate |
$51.80 |
| Max. Negotiated Rate |
$74.00 |
| Rate for Payer: Aetna Commercial |
$70.30
|
| Rate for Payer: Aetna Medicare |
$66.60
|
| Rate for Payer: BCBS MT CHIP |
$66.60
|
| Rate for Payer: BCBS MT Closed Plan Network |
$70.30
|
| Rate for Payer: BCBS MT HealthLink |
$66.60
|
| Rate for Payer: BCBS MT Medicare |
$66.60
|
| Rate for Payer: BCBS MT POS |
$70.30
|
| Rate for Payer: BCBS MT Traditional |
$74.00
|
| Rate for Payer: Cash Price |
$66.60
|
| Rate for Payer: Cigna Commercial |
$70.30
|
| Rate for Payer: Cigna Medicare |
$66.60
|
| Rate for Payer: Medicaid All Medicaid |
$68.08
|
| Rate for Payer: Medicare All Medicare |
$51.80
|
| Rate for Payer: Monida Allegiance |
$70.30
|
| Rate for Payer: Monida First Choice Health |
$71.78
|
| Rate for Payer: Monida Montana Health Co-op |
$70.30
|
| Rate for Payer: Monida PacificSource |
$70.30
|
|
|
PRO FEE INJ FACET JNT C/T 2L W/IMA 64491
|
Professional
|
Both
|
$227.00
|
|
|
Service Code
|
HCPCS 64491
|
| Hospital Charge Code |
764491
|
|
Hospital Revenue Code
|
964
|
| Min. Negotiated Rate |
$158.90 |
| Max. Negotiated Rate |
$227.00 |
| Rate for Payer: Aetna Commercial |
$215.65
|
| Rate for Payer: Aetna Medicare |
$204.30
|
| Rate for Payer: BCBS MT CHIP |
$204.30
|
| Rate for Payer: BCBS MT Closed Plan Network |
$215.65
|
| Rate for Payer: BCBS MT HealthLink |
$204.30
|
| Rate for Payer: BCBS MT Medicare |
$204.30
|
| Rate for Payer: BCBS MT POS |
$215.65
|
| Rate for Payer: BCBS MT Traditional |
$227.00
|
| Rate for Payer: Cash Price |
$204.30
|
| Rate for Payer: Cigna Commercial |
$215.65
|
| Rate for Payer: Cigna Medicare |
$204.30
|
| Rate for Payer: Medicaid All Medicaid |
$208.84
|
| Rate for Payer: Medicare All Medicare |
$158.90
|
| Rate for Payer: Monida Allegiance |
$215.65
|
| Rate for Payer: Monida First Choice Health |
$220.19
|
| Rate for Payer: Monida Montana Health Co-op |
$215.65
|
| Rate for Payer: Monida PacificSource |
$215.65
|
|
|
PRO FEE INTERCOSTAL NV BLK EA ADD 64421
|
Professional
|
Both
|
$124.00
|
|
|
Service Code
|
HCPCS 64421
|
| Hospital Charge Code |
764421
|
|
Hospital Revenue Code
|
964
|
| Min. Negotiated Rate |
$86.80 |
| Max. Negotiated Rate |
$124.00 |
| Rate for Payer: Aetna Commercial |
$117.80
|
| Rate for Payer: Aetna Medicare |
$111.60
|
| Rate for Payer: BCBS MT CHIP |
$111.60
|
| Rate for Payer: BCBS MT Closed Plan Network |
$117.80
|
| Rate for Payer: BCBS MT HealthLink |
$111.60
|
| Rate for Payer: BCBS MT Medicare |
$111.60
|
| Rate for Payer: BCBS MT POS |
$117.80
|
| Rate for Payer: BCBS MT Traditional |
$124.00
|
| Rate for Payer: Cash Price |
$111.60
|
| Rate for Payer: Cigna Commercial |
$117.80
|
| Rate for Payer: Cigna Medicare |
$111.60
|
| Rate for Payer: Medicaid All Medicaid |
$114.08
|
| Rate for Payer: Medicare All Medicare |
$86.80
|
| Rate for Payer: Monida Allegiance |
$117.80
|
| Rate for Payer: Monida First Choice Health |
$120.28
|
| Rate for Payer: Monida Montana Health Co-op |
$117.80
|
| Rate for Payer: Monida PacificSource |
$117.80
|
|
|
PRO FEE INTERMED JOINT INJ W/O US 20605
|
Professional
|
Both
|
$200.00
|
|
|
Service Code
|
HCPCS 20605
|
| Hospital Charge Code |
720605
|
|
Hospital Revenue Code
|
964
|
| Min. Negotiated Rate |
$140.00 |
| Max. Negotiated Rate |
$200.00 |
| Rate for Payer: Aetna Commercial |
$190.00
|
| Rate for Payer: Aetna Medicare |
$180.00
|
| Rate for Payer: BCBS MT CHIP |
$180.00
|
| Rate for Payer: BCBS MT Closed Plan Network |
$190.00
|
| Rate for Payer: BCBS MT HealthLink |
$180.00
|
| Rate for Payer: BCBS MT Medicare |
$180.00
|
| Rate for Payer: BCBS MT POS |
$190.00
|
| Rate for Payer: BCBS MT Traditional |
$200.00
|
| Rate for Payer: Cash Price |
$180.00
|
| Rate for Payer: Cigna Commercial |
$190.00
|
| Rate for Payer: Cigna Medicare |
$180.00
|
| Rate for Payer: Medicaid All Medicaid |
$184.00
|
| Rate for Payer: Medicare All Medicare |
$140.00
|
| Rate for Payer: Monida Allegiance |
$190.00
|
| Rate for Payer: Monida First Choice Health |
$194.00
|
| Rate for Payer: Monida Montana Health Co-op |
$190.00
|
| Rate for Payer: Monida PacificSource |
$190.00
|
|
|
PRO FEE INT/INJ GENICULAR NERVE 64454
|
Professional
|
Both
|
$197.00
|
|
|
Service Code
|
HCPCS 64454
|
| Hospital Charge Code |
764454
|
|
Hospital Revenue Code
|
964
|
| Min. Negotiated Rate |
$137.90 |
| Max. Negotiated Rate |
$197.00 |
| Rate for Payer: Aetna Commercial |
$187.15
|
| Rate for Payer: Aetna Medicare |
$177.30
|
| Rate for Payer: BCBS MT CHIP |
$177.30
|
| Rate for Payer: BCBS MT Closed Plan Network |
$187.15
|
| Rate for Payer: BCBS MT HealthLink |
$177.30
|
| Rate for Payer: BCBS MT Medicare |
$177.30
|
| Rate for Payer: BCBS MT POS |
$187.15
|
| Rate for Payer: BCBS MT Traditional |
$197.00
|
| Rate for Payer: Cash Price |
$177.30
|
| Rate for Payer: Cigna Commercial |
$187.15
|
| Rate for Payer: Cigna Medicare |
$177.30
|
| Rate for Payer: Medicaid All Medicaid |
$181.24
|
| Rate for Payer: Medicare All Medicare |
$137.90
|
| Rate for Payer: Monida Allegiance |
$187.15
|
| Rate for Payer: Monida First Choice Health |
$191.09
|
| Rate for Payer: Monida Montana Health Co-op |
$187.15
|
| Rate for Payer: Monida PacificSource |
$187.15
|
|
|
PRO FEE INTRCOST NRVE BLOCK SINGLE 64420
|
Professional
|
Both
|
$240.00
|
|
|
Service Code
|
HCPCS 64420
|
| Hospital Charge Code |
764420
|
|
Hospital Revenue Code
|
964
|
| Min. Negotiated Rate |
$168.00 |
| Max. Negotiated Rate |
$240.00 |
| Rate for Payer: Aetna Commercial |
$228.00
|
| Rate for Payer: Aetna Medicare |
$216.00
|
| Rate for Payer: BCBS MT CHIP |
$216.00
|
| Rate for Payer: BCBS MT Closed Plan Network |
$228.00
|
| Rate for Payer: BCBS MT HealthLink |
$216.00
|
| Rate for Payer: BCBS MT Medicare |
$216.00
|
| Rate for Payer: BCBS MT POS |
$228.00
|
| Rate for Payer: BCBS MT Traditional |
$240.00
|
| Rate for Payer: Cash Price |
$216.00
|
| Rate for Payer: Cigna Commercial |
$228.00
|
| Rate for Payer: Cigna Medicare |
$216.00
|
| Rate for Payer: Medicaid All Medicaid |
$220.80
|
| Rate for Payer: Medicare All Medicare |
$168.00
|
| Rate for Payer: Monida Allegiance |
$228.00
|
| Rate for Payer: Monida First Choice Health |
$232.80
|
| Rate for Payer: Monida Montana Health Co-op |
$228.00
|
| Rate for Payer: Monida PacificSource |
$228.00
|
|
|
PRO FEE LAC REPAIR CMPL FC/HNADD ON =>5C
|
Professional
|
Both
|
$162.00
|
|
|
Service Code
|
HCPCS 13133 AQ
|
| Hospital Charge Code |
713133
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$113.40 |
| Max. Negotiated Rate |
$162.00 |
| Rate for Payer: Aetna Commercial |
$153.90
|
| Rate for Payer: Aetna Medicare |
$145.80
|
| Rate for Payer: BCBS MT CHIP |
$145.80
|
| Rate for Payer: BCBS MT Closed Plan Network |
$153.90
|
| Rate for Payer: BCBS MT HealthLink |
$145.80
|
| Rate for Payer: BCBS MT Medicare |
$145.80
|
| Rate for Payer: BCBS MT POS |
$153.90
|
| Rate for Payer: BCBS MT Traditional |
$162.00
|
| Rate for Payer: Cash Price |
$145.80
|
| Rate for Payer: Cigna Commercial |
$153.90
|
| Rate for Payer: Cigna Medicare |
$145.80
|
| Rate for Payer: Medicaid All Medicaid |
$149.04
|
| Rate for Payer: Medicare All Medicare |
$113.40
|
| Rate for Payer: Monida Allegiance |
$153.90
|
| Rate for Payer: Monida First Choice Health |
$157.14
|
| Rate for Payer: Monida Montana Health Co-op |
$153.90
|
| Rate for Payer: Monida PacificSource |
$153.90
|
|
|
PRO FEE LAC REPAIR COMPLEX 2.6-7.5CM
|
Professional
|
Both
|
$294.00
|
|
|
Service Code
|
HCPCS 13121 AQ
|
| Hospital Charge Code |
713121
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$205.80 |
| Max. Negotiated Rate |
$294.00 |
| Rate for Payer: Aetna Commercial |
$279.30
|
| Rate for Payer: Aetna Medicare |
$264.60
|
| Rate for Payer: BCBS MT CHIP |
$264.60
|
| Rate for Payer: BCBS MT Closed Plan Network |
$279.30
|
| Rate for Payer: BCBS MT HealthLink |
$264.60
|
| Rate for Payer: BCBS MT Medicare |
$264.60
|
| Rate for Payer: BCBS MT POS |
$279.30
|
| Rate for Payer: BCBS MT Traditional |
$294.00
|
| Rate for Payer: Cash Price |
$264.60
|
| Rate for Payer: Cigna Commercial |
$279.30
|
| Rate for Payer: Cigna Medicare |
$264.60
|
| Rate for Payer: Medicaid All Medicaid |
$270.48
|
| Rate for Payer: Medicare All Medicare |
$205.80
|
| Rate for Payer: Monida Allegiance |
$279.30
|
| Rate for Payer: Monida First Choice Health |
$285.18
|
| Rate for Payer: Monida Montana Health Co-op |
$279.30
|
| Rate for Payer: Monida PacificSource |
$279.30
|
|
|
PRO FEE LAC REPAIR COMPLEX 2.6-7.5CM
|
Professional
|
Both
|
$352.00
|
|
|
Service Code
|
HCPCS 13132 AQ
|
| Hospital Charge Code |
713132
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$246.40 |
| Max. Negotiated Rate |
$352.00 |
| Rate for Payer: Aetna Commercial |
$334.40
|
| Rate for Payer: Aetna Medicare |
$316.80
|
| Rate for Payer: BCBS MT CHIP |
$316.80
|
| Rate for Payer: BCBS MT Closed Plan Network |
$334.40
|
| Rate for Payer: BCBS MT HealthLink |
$316.80
|
| Rate for Payer: BCBS MT Medicare |
$316.80
|
| Rate for Payer: BCBS MT POS |
$334.40
|
| Rate for Payer: BCBS MT Traditional |
$352.00
|
| Rate for Payer: Cash Price |
$316.80
|
| Rate for Payer: Cigna Commercial |
$334.40
|
| Rate for Payer: Cigna Medicare |
$316.80
|
| Rate for Payer: Medicaid All Medicaid |
$323.84
|
| Rate for Payer: Medicare All Medicare |
$246.40
|
| Rate for Payer: Monida Allegiance |
$334.40
|
| Rate for Payer: Monida First Choice Health |
$341.44
|
| Rate for Payer: Monida Montana Health Co-op |
$334.40
|
| Rate for Payer: Monida PacificSource |
$334.40
|
|
