|
PRO FEE LAC REPAIR SIMPLE=<2.5CM
|
Professional
|
Both
|
$63.00
|
|
|
Service Code
|
HCPCS 12001 AQ
|
| Hospital Charge Code |
712001
|
|
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 LAC REPAIR SIMPLE 2.6-7.5CM
|
Professional
|
Both
|
$84.00
|
|
|
Service Code
|
HCPCS 12002 AQ
|
| Hospital Charge Code |
712002
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$58.80 |
| Max. Negotiated Rate |
$84.00 |
| Rate for Payer: Aetna Commercial |
$79.80
|
| Rate for Payer: Aetna Medicare |
$75.60
|
| Rate for Payer: BCBS MT CHIP |
$75.60
|
| Rate for Payer: BCBS MT Closed Plan Network |
$79.80
|
| Rate for Payer: BCBS MT HealthLink |
$75.60
|
| Rate for Payer: BCBS MT Medicare |
$75.60
|
| Rate for Payer: BCBS MT POS |
$79.80
|
| Rate for Payer: BCBS MT Traditional |
$84.00
|
| Rate for Payer: Cash Price |
$75.60
|
| Rate for Payer: Cigna Commercial |
$79.80
|
| Rate for Payer: Cigna Medicare |
$75.60
|
| Rate for Payer: Medicaid All Medicaid |
$77.28
|
| Rate for Payer: Medicare All Medicare |
$58.80
|
| Rate for Payer: Monida Allegiance |
$79.80
|
| Rate for Payer: Monida First Choice Health |
$81.48
|
| Rate for Payer: Monida Montana Health Co-op |
$79.80
|
| Rate for Payer: Monida PacificSource |
$79.80
|
|
|
PRO FEE LAC REPAIR SIMPLE 7.6-12.5CM
|
Professional
|
Both
|
$105.00
|
|
|
Service Code
|
HCPCS 12004 AQ
|
| Hospital Charge Code |
712004
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$73.50 |
| Max. Negotiated Rate |
$105.00 |
| Rate for Payer: Aetna Commercial |
$99.75
|
| Rate for Payer: Aetna Medicare |
$94.50
|
| Rate for Payer: BCBS MT CHIP |
$94.50
|
| Rate for Payer: BCBS MT Closed Plan Network |
$99.75
|
| Rate for Payer: BCBS MT HealthLink |
$94.50
|
| Rate for Payer: BCBS MT Medicare |
$94.50
|
| Rate for Payer: BCBS MT POS |
$99.75
|
| Rate for Payer: BCBS MT Traditional |
$105.00
|
| Rate for Payer: Cash Price |
$94.50
|
| Rate for Payer: Cigna Commercial |
$99.75
|
| Rate for Payer: Cigna Medicare |
$94.50
|
| Rate for Payer: Medicaid All Medicaid |
$96.60
|
| Rate for Payer: Medicare All Medicare |
$73.50
|
| Rate for Payer: Monida Allegiance |
$99.75
|
| Rate for Payer: Monida First Choice Health |
$101.85
|
| Rate for Payer: Monida Montana Health Co-op |
$99.75
|
| Rate for Payer: Monida PacificSource |
$99.75
|
|
|
PRO FEE MAJOR JOINT INJ W/O US 20610
|
Professional
|
Both
|
$282.00
|
|
|
Service Code
|
HCPCS 20610
|
| Hospital Charge Code |
720610
|
|
Hospital Revenue Code
|
964
|
| Min. Negotiated Rate |
$197.40 |
| Max. Negotiated Rate |
$282.00 |
| Rate for Payer: Aetna Commercial |
$267.90
|
| Rate for Payer: Aetna Medicare |
$253.80
|
| Rate for Payer: BCBS MT CHIP |
$253.80
|
| Rate for Payer: BCBS MT Closed Plan Network |
$267.90
|
| Rate for Payer: BCBS MT HealthLink |
$253.80
|
| Rate for Payer: BCBS MT Medicare |
$253.80
|
| Rate for Payer: BCBS MT POS |
$267.90
|
| Rate for Payer: BCBS MT Traditional |
$282.00
|
| Rate for Payer: Cash Price |
$253.80
|
| Rate for Payer: Cigna Commercial |
$267.90
|
| Rate for Payer: Cigna Medicare |
$253.80
|
| Rate for Payer: Medicaid All Medicaid |
$259.44
|
| Rate for Payer: Medicare All Medicare |
$197.40
|
| Rate for Payer: Monida Allegiance |
$267.90
|
| Rate for Payer: Monida First Choice Health |
$273.54
|
| Rate for Payer: Monida Montana Health Co-op |
$267.90
|
| Rate for Payer: Monida PacificSource |
$267.90
|
|
|
PRO FEE OP IJ DESTR, PLANTAR NERV 64632
|
Professional
|
Both
|
$127.00
|
|
|
Service Code
|
HCPCS 64632
|
| Hospital Charge Code |
764632
|
|
Hospital Revenue Code
|
964
|
| Min. Negotiated Rate |
$88.90 |
| Max. Negotiated Rate |
$127.00 |
| Rate for Payer: Aetna Commercial |
$120.65
|
| Rate for Payer: Aetna Medicare |
$114.30
|
| Rate for Payer: BCBS MT CHIP |
$114.30
|
| Rate for Payer: BCBS MT Closed Plan Network |
$120.65
|
| Rate for Payer: BCBS MT HealthLink |
$114.30
|
| Rate for Payer: BCBS MT Medicare |
$114.30
|
| Rate for Payer: BCBS MT POS |
$120.65
|
| Rate for Payer: BCBS MT Traditional |
$127.00
|
| Rate for Payer: Cash Price |
$114.30
|
| Rate for Payer: Cigna Commercial |
$120.65
|
| Rate for Payer: Cigna Medicare |
$114.30
|
| Rate for Payer: Medicaid All Medicaid |
$116.84
|
| Rate for Payer: Medicare All Medicare |
$88.90
|
| Rate for Payer: Monida Allegiance |
$120.65
|
| Rate for Payer: Monida First Choice Health |
$123.19
|
| Rate for Payer: Monida Montana Health Co-op |
$120.65
|
| Rate for Payer: Monida PacificSource |
$120.65
|
|
|
PRO FEE OP IJ DESTR, PUDENDAL NERV 64630
|
Professional
|
Both
|
$831.00
|
|
|
Service Code
|
HCPCS 64630
|
| Hospital Charge Code |
764630
|
|
Hospital Revenue Code
|
964
|
| Min. Negotiated Rate |
$581.70 |
| Max. Negotiated Rate |
$831.00 |
| Rate for Payer: Aetna Commercial |
$789.45
|
| Rate for Payer: Aetna Medicare |
$747.90
|
| Rate for Payer: BCBS MT CHIP |
$747.90
|
| Rate for Payer: BCBS MT Closed Plan Network |
$789.45
|
| Rate for Payer: BCBS MT HealthLink |
$747.90
|
| Rate for Payer: BCBS MT Medicare |
$747.90
|
| Rate for Payer: BCBS MT POS |
$789.45
|
| Rate for Payer: BCBS MT Traditional |
$831.00
|
| Rate for Payer: Cash Price |
$747.90
|
| Rate for Payer: Cigna Commercial |
$789.45
|
| Rate for Payer: Cigna Medicare |
$747.90
|
| Rate for Payer: Medicaid All Medicaid |
$764.52
|
| Rate for Payer: Medicare All Medicare |
$581.70
|
| Rate for Payer: Monida Allegiance |
$789.45
|
| Rate for Payer: Monida First Choice Health |
$806.07
|
| Rate for Payer: Monida Montana Health Co-op |
$789.45
|
| Rate for Payer: Monida PacificSource |
$789.45
|
|
|
PRO FEE OP IJ DST. F NER MIGRN TRT 64615
|
Professional
|
Both
|
$165.00
|
|
|
Service Code
|
HCPCS 64615
|
| Hospital Charge Code |
764615
|
|
Hospital Revenue Code
|
964
|
| Min. Negotiated Rate |
$115.50 |
| Max. Negotiated Rate |
$165.00 |
| Rate for Payer: Aetna Commercial |
$156.75
|
| Rate for Payer: Aetna Medicare |
$148.50
|
| Rate for Payer: BCBS MT CHIP |
$148.50
|
| Rate for Payer: BCBS MT Closed Plan Network |
$156.75
|
| Rate for Payer: BCBS MT HealthLink |
$148.50
|
| Rate for Payer: BCBS MT Medicare |
$148.50
|
| Rate for Payer: BCBS MT POS |
$156.75
|
| Rate for Payer: BCBS MT Traditional |
$165.00
|
| Rate for Payer: Cash Price |
$148.50
|
| Rate for Payer: Cigna Commercial |
$156.75
|
| Rate for Payer: Cigna Medicare |
$148.50
|
| Rate for Payer: Medicaid All Medicaid |
$151.80
|
| Rate for Payer: Medicare All Medicare |
$115.50
|
| Rate for Payer: Monida Allegiance |
$156.75
|
| Rate for Payer: Monida First Choice Health |
$160.05
|
| Rate for Payer: Monida Montana Health Co-op |
$156.75
|
| Rate for Payer: Monida PacificSource |
$156.75
|
|
|
PRO FEE OP IJ GREATER OCCIP NV BLK 64405
|
Professional
|
Both
|
$189.00
|
|
|
Service Code
|
HCPCS 64405
|
| Hospital Charge Code |
764405
|
|
Hospital Revenue Code
|
964
|
| Min. Negotiated Rate |
$132.30 |
| Max. Negotiated Rate |
$189.00 |
| Rate for Payer: Aetna Commercial |
$179.55
|
| Rate for Payer: Aetna Medicare |
$170.10
|
| Rate for Payer: BCBS MT CHIP |
$170.10
|
| Rate for Payer: BCBS MT Closed Plan Network |
$179.55
|
| Rate for Payer: BCBS MT HealthLink |
$170.10
|
| Rate for Payer: BCBS MT Medicare |
$170.10
|
| Rate for Payer: BCBS MT POS |
$179.55
|
| Rate for Payer: BCBS MT Traditional |
$189.00
|
| Rate for Payer: Cash Price |
$170.10
|
| Rate for Payer: Cigna Commercial |
$179.55
|
| Rate for Payer: Cigna Medicare |
$170.10
|
| Rate for Payer: Medicaid All Medicaid |
$173.88
|
| Rate for Payer: Medicare All Medicare |
$132.30
|
| Rate for Payer: Monida Allegiance |
$179.55
|
| Rate for Payer: Monida First Choice Health |
$183.33
|
| Rate for Payer: Monida Montana Health Co-op |
$179.55
|
| Rate for Payer: Monida PacificSource |
$179.55
|
|
|
PRO FEE OP IJ RFA C/T 1ST JOINT 64633
|
Professional
|
Both
|
$659.00
|
|
|
Service Code
|
HCPCS 64633
|
| Hospital Charge Code |
764633
|
|
Hospital Revenue Code
|
964
|
| Min. Negotiated Rate |
$461.30 |
| Max. Negotiated Rate |
$659.00 |
| Rate for Payer: Aetna Commercial |
$626.05
|
| Rate for Payer: Aetna Medicare |
$593.10
|
| Rate for Payer: BCBS MT CHIP |
$593.10
|
| Rate for Payer: BCBS MT Closed Plan Network |
$626.05
|
| Rate for Payer: BCBS MT HealthLink |
$593.10
|
| Rate for Payer: BCBS MT Medicare |
$593.10
|
| Rate for Payer: BCBS MT POS |
$626.05
|
| Rate for Payer: BCBS MT Traditional |
$659.00
|
| Rate for Payer: Cash Price |
$593.10
|
| Rate for Payer: Cigna Commercial |
$626.05
|
| Rate for Payer: Cigna Medicare |
$593.10
|
| Rate for Payer: Medicaid All Medicaid |
$606.28
|
| Rate for Payer: Medicare All Medicare |
$461.30
|
| Rate for Payer: Monida Allegiance |
$626.05
|
| Rate for Payer: Monida First Choice Health |
$639.23
|
| Rate for Payer: Monida Montana Health Co-op |
$626.05
|
| Rate for Payer: Monida PacificSource |
$626.05
|
|
|
PRO FEE OP IJ RFA C/T EA AD ON JT 64634
|
Professional
|
Both
|
$277.00
|
|
|
Service Code
|
HCPCS 64634
|
| Hospital Charge Code |
764634
|
|
Hospital Revenue Code
|
964
|
| Min. Negotiated Rate |
$193.90 |
| Max. Negotiated Rate |
$277.00 |
| Rate for Payer: Aetna Commercial |
$263.15
|
| Rate for Payer: Aetna Medicare |
$249.30
|
| Rate for Payer: BCBS MT CHIP |
$249.30
|
| Rate for Payer: BCBS MT Closed Plan Network |
$263.15
|
| Rate for Payer: BCBS MT HealthLink |
$249.30
|
| Rate for Payer: BCBS MT Medicare |
$249.30
|
| Rate for Payer: BCBS MT POS |
$263.15
|
| Rate for Payer: BCBS MT Traditional |
$277.00
|
| Rate for Payer: Cash Price |
$249.30
|
| Rate for Payer: Cigna Commercial |
$263.15
|
| Rate for Payer: Cigna Medicare |
$249.30
|
| Rate for Payer: Medicaid All Medicaid |
$254.84
|
| Rate for Payer: Medicare All Medicare |
$193.90
|
| Rate for Payer: Monida Allegiance |
$263.15
|
| Rate for Payer: Monida First Choice Health |
$268.69
|
| Rate for Payer: Monida Montana Health Co-op |
$263.15
|
| Rate for Payer: Monida PacificSource |
$263.15
|
|
|
PRO FEE OP IJ RFA PERPH NV/SUPSCAP 64640
|
Professional
|
Both
|
$465.00
|
|
|
Service Code
|
HCPCS 64640
|
| Hospital Charge Code |
764640
|
|
Hospital Revenue Code
|
964
|
| Min. Negotiated Rate |
$325.50 |
| Max. Negotiated Rate |
$465.00 |
| Rate for Payer: Aetna Commercial |
$441.75
|
| Rate for Payer: Aetna Medicare |
$418.50
|
| Rate for Payer: BCBS MT CHIP |
$418.50
|
| Rate for Payer: BCBS MT Closed Plan Network |
$441.75
|
| Rate for Payer: BCBS MT HealthLink |
$418.50
|
| Rate for Payer: BCBS MT Medicare |
$418.50
|
| Rate for Payer: BCBS MT POS |
$441.75
|
| Rate for Payer: BCBS MT Traditional |
$465.00
|
| Rate for Payer: Cash Price |
$418.50
|
| Rate for Payer: Cigna Commercial |
$441.75
|
| Rate for Payer: Cigna Medicare |
$418.50
|
| Rate for Payer: Medicaid All Medicaid |
$427.80
|
| Rate for Payer: Medicare All Medicare |
$325.50
|
| Rate for Payer: Monida Allegiance |
$441.75
|
| Rate for Payer: Monida First Choice Health |
$451.05
|
| Rate for Payer: Monida Montana Health Co-op |
$441.75
|
| Rate for Payer: Monida PacificSource |
$441.75
|
|
|
PRO FEE OP IJ TRANSFOR L/S ADD 64484
|
Professional
|
Both
|
$252.00
|
|
|
Service Code
|
HCPCS 64484
|
| Hospital Charge Code |
764484
|
|
Hospital Revenue Code
|
964
|
| Min. Negotiated Rate |
$176.40 |
| Max. Negotiated Rate |
$252.00 |
| Rate for Payer: Aetna Commercial |
$239.40
|
| Rate for Payer: Aetna Medicare |
$226.80
|
| Rate for Payer: BCBS MT CHIP |
$226.80
|
| Rate for Payer: BCBS MT Closed Plan Network |
$239.40
|
| Rate for Payer: BCBS MT HealthLink |
$226.80
|
| Rate for Payer: BCBS MT Medicare |
$226.80
|
| Rate for Payer: BCBS MT POS |
$239.40
|
| Rate for Payer: BCBS MT Traditional |
$252.00
|
| Rate for Payer: Cash Price |
$226.80
|
| Rate for Payer: Cigna Commercial |
$239.40
|
| Rate for Payer: Cigna Medicare |
$226.80
|
| Rate for Payer: Medicaid All Medicaid |
$231.84
|
| Rate for Payer: Medicare All Medicare |
$176.40
|
| Rate for Payer: Monida Allegiance |
$239.40
|
| Rate for Payer: Monida First Choice Health |
$244.44
|
| Rate for Payer: Monida Montana Health Co-op |
$239.40
|
| Rate for Payer: Monida PacificSource |
$239.40
|
|
|
PRO FEE OP INJ BRACHIAL PLEX W/IMG 64415
|
Professional
|
Both
|
$189.00
|
|
|
Service Code
|
HCPCS 64415
|
| Hospital Charge Code |
764415
|
|
Hospital Revenue Code
|
964
|
| Min. Negotiated Rate |
$132.30 |
| Max. Negotiated Rate |
$189.00 |
| Rate for Payer: Aetna Commercial |
$179.55
|
| Rate for Payer: Aetna Medicare |
$170.10
|
| Rate for Payer: BCBS MT CHIP |
$170.10
|
| Rate for Payer: BCBS MT Closed Plan Network |
$179.55
|
| Rate for Payer: BCBS MT HealthLink |
$170.10
|
| Rate for Payer: BCBS MT Medicare |
$170.10
|
| Rate for Payer: BCBS MT POS |
$179.55
|
| Rate for Payer: BCBS MT Traditional |
$189.00
|
| Rate for Payer: Cash Price |
$170.10
|
| Rate for Payer: Cigna Commercial |
$179.55
|
| Rate for Payer: Cigna Medicare |
$170.10
|
| Rate for Payer: Medicaid All Medicaid |
$173.88
|
| Rate for Payer: Medicare All Medicare |
$132.30
|
| Rate for Payer: Monida Allegiance |
$179.55
|
| Rate for Payer: Monida First Choice Health |
$183.33
|
| Rate for Payer: Monida Montana Health Co-op |
$179.55
|
| Rate for Payer: Monida PacificSource |
$179.55
|
|
|
PRO FEE OP INJ CELIAC PLEX BLOCK 64530
|
Professional
|
Both
|
$520.00
|
|
|
Service Code
|
HCPCS 64530
|
| Hospital Charge Code |
764530
|
|
Hospital Revenue Code
|
964
|
| Min. Negotiated Rate |
$364.00 |
| Max. Negotiated Rate |
$520.00 |
| Rate for Payer: Aetna Commercial |
$494.00
|
| Rate for Payer: Aetna Medicare |
$468.00
|
| Rate for Payer: BCBS MT CHIP |
$468.00
|
| Rate for Payer: BCBS MT Closed Plan Network |
$494.00
|
| Rate for Payer: BCBS MT HealthLink |
$468.00
|
| Rate for Payer: BCBS MT Medicare |
$468.00
|
| Rate for Payer: BCBS MT POS |
$494.00
|
| Rate for Payer: BCBS MT Traditional |
$520.00
|
| Rate for Payer: Cash Price |
$468.00
|
| Rate for Payer: Cigna Commercial |
$494.00
|
| Rate for Payer: Cigna Medicare |
$468.00
|
| Rate for Payer: Medicaid All Medicaid |
$478.40
|
| Rate for Payer: Medicare All Medicare |
$364.00
|
| Rate for Payer: Monida Allegiance |
$494.00
|
| Rate for Payer: Monida First Choice Health |
$504.40
|
| Rate for Payer: Monida Montana Health Co-op |
$494.00
|
| Rate for Payer: Monida PacificSource |
$494.00
|
|
|
PRO FEE OP INJ DEST OF FACIAL NER 64612
|
Professional
|
Both
|
$104.00
|
|
|
Service Code
|
HCPCS 64612
|
| Hospital Charge Code |
764612
|
|
Hospital Revenue Code
|
964
|
| Min. Negotiated Rate |
$72.80 |
| Max. Negotiated Rate |
$104.00 |
| Rate for Payer: Aetna Commercial |
$98.80
|
| Rate for Payer: Aetna Medicare |
$93.60
|
| Rate for Payer: BCBS MT CHIP |
$93.60
|
| Rate for Payer: BCBS MT Closed Plan Network |
$98.80
|
| Rate for Payer: BCBS MT HealthLink |
$93.60
|
| Rate for Payer: BCBS MT Medicare |
$93.60
|
| Rate for Payer: BCBS MT POS |
$98.80
|
| Rate for Payer: BCBS MT Traditional |
$104.00
|
| Rate for Payer: Cash Price |
$93.60
|
| Rate for Payer: Cigna Commercial |
$98.80
|
| Rate for Payer: Cigna Medicare |
$93.60
|
| Rate for Payer: Medicaid All Medicaid |
$95.68
|
| Rate for Payer: Medicare All Medicare |
$72.80
|
| Rate for Payer: Monida Allegiance |
$98.80
|
| Rate for Payer: Monida First Choice Health |
$100.88
|
| Rate for Payer: Monida Montana Health Co-op |
$98.80
|
| Rate for Payer: Monida PacificSource |
$98.80
|
|
|
PRO FEE OP INJ FACET JNT C/T 1L 64490
|
Professional
|
Both
|
$449.00
|
|
|
Service Code
|
HCPCS 64490
|
| Hospital Charge Code |
764490
|
|
Hospital Revenue Code
|
964
|
| Min. Negotiated Rate |
$314.30 |
| Max. Negotiated Rate |
$449.00 |
| Rate for Payer: Aetna Commercial |
$426.55
|
| Rate for Payer: Aetna Medicare |
$404.10
|
| Rate for Payer: BCBS MT CHIP |
$404.10
|
| Rate for Payer: BCBS MT Closed Plan Network |
$426.55
|
| Rate for Payer: BCBS MT HealthLink |
$404.10
|
| Rate for Payer: BCBS MT Medicare |
$404.10
|
| Rate for Payer: BCBS MT POS |
$426.55
|
| Rate for Payer: BCBS MT Traditional |
$449.00
|
| Rate for Payer: Cash Price |
$404.10
|
| Rate for Payer: Cigna Commercial |
$426.55
|
| Rate for Payer: Cigna Medicare |
$404.10
|
| Rate for Payer: Medicaid All Medicaid |
$413.08
|
| Rate for Payer: Medicare All Medicare |
$314.30
|
| Rate for Payer: Monida Allegiance |
$426.55
|
| Rate for Payer: Monida First Choice Health |
$435.53
|
| Rate for Payer: Monida Montana Health Co-op |
$426.55
|
| Rate for Payer: Monida PacificSource |
$426.55
|
|
|
PRO FEE OP INJ FACET JNT C/T 3RDL 64492
|
Professional
|
Both
|
$218.00
|
|
|
Service Code
|
HCPCS 64492
|
| Hospital Charge Code |
764492
|
|
Hospital Revenue Code
|
964
|
| Min. Negotiated Rate |
$152.60 |
| Max. Negotiated Rate |
$218.00 |
| Rate for Payer: Aetna Commercial |
$207.10
|
| Rate for Payer: Aetna Medicare |
$196.20
|
| Rate for Payer: BCBS MT CHIP |
$196.20
|
| Rate for Payer: BCBS MT Closed Plan Network |
$207.10
|
| Rate for Payer: BCBS MT HealthLink |
$196.20
|
| Rate for Payer: BCBS MT Medicare |
$196.20
|
| Rate for Payer: BCBS MT POS |
$207.10
|
| Rate for Payer: BCBS MT Traditional |
$218.00
|
| Rate for Payer: Cash Price |
$196.20
|
| Rate for Payer: Cigna Commercial |
$207.10
|
| Rate for Payer: Cigna Medicare |
$196.20
|
| Rate for Payer: Medicaid All Medicaid |
$200.56
|
| Rate for Payer: Medicare All Medicare |
$152.60
|
| Rate for Payer: Monida Allegiance |
$207.10
|
| Rate for Payer: Monida First Choice Health |
$211.46
|
| Rate for Payer: Monida Montana Health Co-op |
$207.10
|
| Rate for Payer: Monida PacificSource |
$207.10
|
|
|
PRO FEE OP INJ FACET JNT L/S 1 L64493
|
Professional
|
Both
|
$457.00
|
|
|
Service Code
|
HCPCS 64493
|
| Hospital Charge Code |
764493
|
|
Hospital Revenue Code
|
964
|
| Min. Negotiated Rate |
$319.90 |
| Max. Negotiated Rate |
$457.00 |
| Rate for Payer: Aetna Commercial |
$434.15
|
| Rate for Payer: Aetna Medicare |
$411.30
|
| Rate for Payer: BCBS MT CHIP |
$411.30
|
| Rate for Payer: BCBS MT Closed Plan Network |
$434.15
|
| Rate for Payer: BCBS MT HealthLink |
$411.30
|
| Rate for Payer: BCBS MT Medicare |
$411.30
|
| Rate for Payer: BCBS MT POS |
$434.15
|
| Rate for Payer: BCBS MT Traditional |
$457.00
|
| Rate for Payer: Cash Price |
$411.30
|
| Rate for Payer: Cigna Commercial |
$434.15
|
| Rate for Payer: Cigna Medicare |
$411.30
|
| Rate for Payer: Medicaid All Medicaid |
$420.44
|
| Rate for Payer: Medicare All Medicare |
$319.90
|
| Rate for Payer: Monida Allegiance |
$434.15
|
| Rate for Payer: Monida First Choice Health |
$443.29
|
| Rate for Payer: Monida Montana Health Co-op |
$434.15
|
| Rate for Payer: Monida PacificSource |
$434.15
|
|
|
PRO FEE OP INJ FACET JNT L/S 2 L 64494
|
Professional
|
Both
|
$236.00
|
|
|
Service Code
|
HCPCS 64494
|
| Hospital Charge Code |
764494
|
|
Hospital Revenue Code
|
964
|
| Min. Negotiated Rate |
$165.20 |
| Max. Negotiated Rate |
$236.00 |
| Rate for Payer: Aetna Commercial |
$224.20
|
| Rate for Payer: Aetna Medicare |
$212.40
|
| Rate for Payer: BCBS MT CHIP |
$212.40
|
| Rate for Payer: BCBS MT Closed Plan Network |
$224.20
|
| Rate for Payer: BCBS MT HealthLink |
$212.40
|
| Rate for Payer: BCBS MT Medicare |
$212.40
|
| Rate for Payer: BCBS MT POS |
$224.20
|
| Rate for Payer: BCBS MT Traditional |
$236.00
|
| Rate for Payer: Cash Price |
$212.40
|
| Rate for Payer: Cigna Commercial |
$224.20
|
| Rate for Payer: Cigna Medicare |
$212.40
|
| Rate for Payer: Medicaid All Medicaid |
$217.12
|
| Rate for Payer: Medicare All Medicare |
$165.20
|
| Rate for Payer: Monida Allegiance |
$224.20
|
| Rate for Payer: Monida First Choice Health |
$228.92
|
| Rate for Payer: Monida Montana Health Co-op |
$224.20
|
| Rate for Payer: Monida PacificSource |
$224.20
|
|
|
PRO FEE OP INJ FACET JNT L/S 3L 64495
|
Professional
|
Both
|
$225.00
|
|
|
Service Code
|
HCPCS 64495
|
| Hospital Charge Code |
764495
|
|
Hospital Revenue Code
|
964
|
| Min. Negotiated Rate |
$157.50 |
| Max. Negotiated Rate |
$225.00 |
| Rate for Payer: Aetna Commercial |
$213.75
|
| Rate for Payer: Aetna Medicare |
$202.50
|
| Rate for Payer: BCBS MT CHIP |
$202.50
|
| Rate for Payer: BCBS MT Closed Plan Network |
$213.75
|
| Rate for Payer: BCBS MT HealthLink |
$202.50
|
| Rate for Payer: BCBS MT Medicare |
$202.50
|
| Rate for Payer: BCBS MT POS |
$213.75
|
| Rate for Payer: BCBS MT Traditional |
$225.00
|
| Rate for Payer: Cash Price |
$202.50
|
| Rate for Payer: Cigna Commercial |
$213.75
|
| Rate for Payer: Cigna Medicare |
$202.50
|
| Rate for Payer: Medicaid All Medicaid |
$207.00
|
| Rate for Payer: Medicare All Medicare |
$157.50
|
| Rate for Payer: Monida Allegiance |
$213.75
|
| Rate for Payer: Monida First Choice Health |
$218.25
|
| Rate for Payer: Monida Montana Health Co-op |
$213.75
|
| Rate for Payer: Monida PacificSource |
$213.75
|
|
|
PRO FEE OP INJ FEMORAL NERVE BLOCK 64447
|
Professional
|
Both
|
$567.00
|
|
|
Service Code
|
HCPCS 64447
|
| Hospital Charge Code |
764447
|
|
Hospital Revenue Code
|
964
|
| Min. Negotiated Rate |
$396.90 |
| Max. Negotiated Rate |
$567.00 |
| Rate for Payer: Aetna Commercial |
$538.65
|
| Rate for Payer: Aetna Medicare |
$510.30
|
| Rate for Payer: BCBS MT CHIP |
$510.30
|
| Rate for Payer: BCBS MT Closed Plan Network |
$538.65
|
| Rate for Payer: BCBS MT HealthLink |
$510.30
|
| Rate for Payer: BCBS MT Medicare |
$510.30
|
| Rate for Payer: BCBS MT POS |
$538.65
|
| Rate for Payer: BCBS MT Traditional |
$567.00
|
| Rate for Payer: Cash Price |
$510.30
|
| Rate for Payer: Cigna Commercial |
$538.65
|
| Rate for Payer: Cigna Medicare |
$510.30
|
| Rate for Payer: Medicaid All Medicaid |
$521.64
|
| Rate for Payer: Medicare All Medicare |
$396.90
|
| Rate for Payer: Monida Allegiance |
$538.65
|
| Rate for Payer: Monida First Choice Health |
$549.99
|
| Rate for Payer: Monida Montana Health Co-op |
$538.65
|
| Rate for Payer: Monida PacificSource |
$538.65
|
|
|
PRO FEE OP INJ ILIOING/ILIOHYPOG 64425
|
Professional
|
Both
|
$233.00
|
|
|
Service Code
|
HCPCS 64425
|
| Hospital Charge Code |
764425
|
|
Hospital Revenue Code
|
964
|
| Min. Negotiated Rate |
$163.10 |
| Max. Negotiated Rate |
$233.00 |
| Rate for Payer: Aetna Commercial |
$221.35
|
| Rate for Payer: Aetna Medicare |
$209.70
|
| Rate for Payer: BCBS MT CHIP |
$209.70
|
| Rate for Payer: BCBS MT Closed Plan Network |
$221.35
|
| Rate for Payer: BCBS MT HealthLink |
$209.70
|
| Rate for Payer: BCBS MT Medicare |
$209.70
|
| Rate for Payer: BCBS MT POS |
$221.35
|
| Rate for Payer: BCBS MT Traditional |
$233.00
|
| Rate for Payer: Cash Price |
$209.70
|
| Rate for Payer: Cigna Commercial |
$221.35
|
| Rate for Payer: Cigna Medicare |
$209.70
|
| Rate for Payer: Medicaid All Medicaid |
$214.36
|
| Rate for Payer: Medicare All Medicare |
$163.10
|
| Rate for Payer: Monida Allegiance |
$221.35
|
| Rate for Payer: Monida First Choice Health |
$226.01
|
| Rate for Payer: Monida Montana Health Co-op |
$221.35
|
| Rate for Payer: Monida PacificSource |
$221.35
|
|
|
PROFEE OP INJ INTERLAM C-T 762321
|
Professional
|
Both
|
$686.00
|
|
|
Service Code
|
HCPCS 62321
|
| Hospital Charge Code |
762321
|
|
Hospital Revenue Code
|
964
|
| Min. Negotiated Rate |
$480.20 |
| Max. Negotiated Rate |
$686.00 |
| Rate for Payer: Aetna Commercial |
$651.70
|
| Rate for Payer: Aetna Medicare |
$617.40
|
| Rate for Payer: BCBS MT CHIP |
$617.40
|
| Rate for Payer: BCBS MT Closed Plan Network |
$651.70
|
| Rate for Payer: BCBS MT HealthLink |
$617.40
|
| Rate for Payer: BCBS MT Medicare |
$617.40
|
| Rate for Payer: BCBS MT POS |
$651.70
|
| Rate for Payer: BCBS MT Traditional |
$686.00
|
| Rate for Payer: Cash Price |
$617.40
|
| Rate for Payer: Cigna Commercial |
$651.70
|
| Rate for Payer: Cigna Medicare |
$617.40
|
| Rate for Payer: Medicaid All Medicaid |
$631.12
|
| Rate for Payer: Medicare All Medicare |
$480.20
|
| Rate for Payer: Monida Allegiance |
$651.70
|
| Rate for Payer: Monida First Choice Health |
$665.42
|
| Rate for Payer: Monida Montana Health Co-op |
$651.70
|
| Rate for Payer: Monida PacificSource |
$651.70
|
|
|
PRO FEE OP INJ INTERLAM LUMB W/IMA 62323
|
Professional
|
Both
|
$665.00
|
|
|
Service Code
|
HCPCS 62323
|
| Hospital Charge Code |
762323
|
|
Hospital Revenue Code
|
964
|
| Min. Negotiated Rate |
$465.50 |
| Max. Negotiated Rate |
$665.00 |
| Rate for Payer: Aetna Commercial |
$631.75
|
| Rate for Payer: Aetna Medicare |
$598.50
|
| Rate for Payer: BCBS MT CHIP |
$598.50
|
| Rate for Payer: BCBS MT Closed Plan Network |
$631.75
|
| Rate for Payer: BCBS MT HealthLink |
$598.50
|
| Rate for Payer: BCBS MT Medicare |
$598.50
|
| Rate for Payer: BCBS MT POS |
$631.75
|
| Rate for Payer: BCBS MT Traditional |
$665.00
|
| Rate for Payer: Cash Price |
$598.50
|
| Rate for Payer: Cigna Commercial |
$631.75
|
| Rate for Payer: Cigna Medicare |
$598.50
|
| Rate for Payer: Medicaid All Medicaid |
$611.80
|
| Rate for Payer: Medicare All Medicare |
$465.50
|
| Rate for Payer: Monida Allegiance |
$631.75
|
| Rate for Payer: Monida First Choice Health |
$645.05
|
| Rate for Payer: Monida Montana Health Co-op |
$631.75
|
| Rate for Payer: Monida PacificSource |
$631.75
|
|
|
PRO FEE OP INJ PERIPHERAL NERVE BLOCK
|
Professional
|
Both
|
$420.00
|
|
|
Service Code
|
HCPCS 64450
|
| Hospital Charge Code |
764450
|
|
Hospital Revenue Code
|
964
|
| Min. Negotiated Rate |
$294.00 |
| Max. Negotiated Rate |
$420.00 |
| Rate for Payer: Aetna Commercial |
$399.00
|
| Rate for Payer: Aetna Medicare |
$378.00
|
| Rate for Payer: BCBS MT CHIP |
$378.00
|
| Rate for Payer: BCBS MT Closed Plan Network |
$399.00
|
| Rate for Payer: BCBS MT HealthLink |
$378.00
|
| Rate for Payer: BCBS MT Medicare |
$378.00
|
| Rate for Payer: BCBS MT POS |
$399.00
|
| Rate for Payer: BCBS MT Traditional |
$420.00
|
| Rate for Payer: Cash Price |
$378.00
|
| Rate for Payer: Cigna Commercial |
$399.00
|
| Rate for Payer: Cigna Medicare |
$378.00
|
| Rate for Payer: Medicaid All Medicaid |
$386.40
|
| Rate for Payer: Medicare All Medicare |
$294.00
|
| Rate for Payer: Monida Allegiance |
$399.00
|
| Rate for Payer: Monida First Choice Health |
$407.40
|
| Rate for Payer: Monida Montana Health Co-op |
$399.00
|
| Rate for Payer: Monida PacificSource |
$399.00
|
|
