|
PRO FEE OP INJ PLANTAR NERVE BLOCK 64455
|
Professional
|
Both
|
$53.00
|
|
|
Service Code
|
HCPCS 64455
|
| Hospital Charge Code |
764455
|
|
Hospital Revenue Code
|
964
|
| Min. Negotiated Rate |
$37.10 |
| Max. Negotiated Rate |
$53.00 |
| Rate for Payer: Aetna Commercial |
$50.35
|
| Rate for Payer: Aetna Medicare |
$47.70
|
| Rate for Payer: BCBS MT CHIP |
$47.70
|
| Rate for Payer: BCBS MT Closed Plan Network |
$50.35
|
| Rate for Payer: BCBS MT HealthLink |
$47.70
|
| Rate for Payer: BCBS MT Medicare |
$47.70
|
| Rate for Payer: BCBS MT POS |
$50.35
|
| Rate for Payer: BCBS MT Traditional |
$53.00
|
| Rate for Payer: Cash Price |
$47.70
|
| Rate for Payer: Cigna Commercial |
$50.35
|
| Rate for Payer: Cigna Medicare |
$47.70
|
| Rate for Payer: Medicaid All Medicaid |
$48.76
|
| Rate for Payer: Medicare All Medicare |
$37.10
|
| Rate for Payer: Monida Allegiance |
$50.35
|
| Rate for Payer: Monida First Choice Health |
$51.41
|
| Rate for Payer: Monida Montana Health Co-op |
$50.35
|
| Rate for Payer: Monida PacificSource |
$50.35
|
|
|
PRO FEE OP INJ RFA L/S 1ST JOINT 64635
|
Professional
|
Both
|
$733.00
|
|
|
Service Code
|
HCPCS 64635
|
| Hospital Charge Code |
764635
|
|
Hospital Revenue Code
|
964
|
| Min. Negotiated Rate |
$513.10 |
| Max. Negotiated Rate |
$733.00 |
| Rate for Payer: Aetna Commercial |
$696.35
|
| Rate for Payer: Aetna Medicare |
$659.70
|
| Rate for Payer: BCBS MT CHIP |
$659.70
|
| Rate for Payer: BCBS MT Closed Plan Network |
$696.35
|
| Rate for Payer: BCBS MT HealthLink |
$659.70
|
| Rate for Payer: BCBS MT Medicare |
$659.70
|
| Rate for Payer: BCBS MT POS |
$696.35
|
| Rate for Payer: BCBS MT Traditional |
$733.00
|
| Rate for Payer: Cash Price |
$659.70
|
| Rate for Payer: Cigna Commercial |
$696.35
|
| Rate for Payer: Cigna Medicare |
$659.70
|
| Rate for Payer: Medicaid All Medicaid |
$674.36
|
| Rate for Payer: Medicare All Medicare |
$513.10
|
| Rate for Payer: Monida Allegiance |
$696.35
|
| Rate for Payer: Monida First Choice Health |
$711.01
|
| Rate for Payer: Monida Montana Health Co-op |
$696.35
|
| Rate for Payer: Monida PacificSource |
$696.35
|
|
|
PRO FEE OP INJ RFA L/S EADD JOINT 64636
|
Professional
|
Both
|
$389.00
|
|
|
Service Code
|
HCPCS 64636
|
| Hospital Charge Code |
764636
|
|
Hospital Revenue Code
|
964
|
| Min. Negotiated Rate |
$272.30 |
| Max. Negotiated Rate |
$389.00 |
| Rate for Payer: Aetna Commercial |
$369.55
|
| Rate for Payer: Aetna Medicare |
$350.10
|
| Rate for Payer: BCBS MT CHIP |
$350.10
|
| Rate for Payer: BCBS MT Closed Plan Network |
$369.55
|
| Rate for Payer: BCBS MT HealthLink |
$350.10
|
| Rate for Payer: BCBS MT Medicare |
$350.10
|
| Rate for Payer: BCBS MT POS |
$369.55
|
| Rate for Payer: BCBS MT Traditional |
$389.00
|
| Rate for Payer: Cash Price |
$350.10
|
| Rate for Payer: Cigna Commercial |
$369.55
|
| Rate for Payer: Cigna Medicare |
$350.10
|
| Rate for Payer: Medicaid All Medicaid |
$357.88
|
| Rate for Payer: Medicare All Medicare |
$272.30
|
| Rate for Payer: Monida Allegiance |
$369.55
|
| Rate for Payer: Monida First Choice Health |
$377.33
|
| Rate for Payer: Monida Montana Health Co-op |
$369.55
|
| Rate for Payer: Monida PacificSource |
$369.55
|
|
|
PRO FEE OP INJ SCIATIC NERVE BLOCK 64445
|
Professional
|
Both
|
$109.00
|
|
|
Service Code
|
HCPCS 64445
|
| Hospital Charge Code |
764445
|
|
Hospital Revenue Code
|
964
|
| Min. Negotiated Rate |
$76.30 |
| Max. Negotiated Rate |
$109.00 |
| Rate for Payer: Aetna Commercial |
$103.55
|
| Rate for Payer: Aetna Medicare |
$98.10
|
| Rate for Payer: BCBS MT CHIP |
$98.10
|
| Rate for Payer: BCBS MT Closed Plan Network |
$103.55
|
| Rate for Payer: BCBS MT HealthLink |
$98.10
|
| Rate for Payer: BCBS MT Medicare |
$98.10
|
| Rate for Payer: BCBS MT POS |
$103.55
|
| Rate for Payer: BCBS MT Traditional |
$109.00
|
| Rate for Payer: Cash Price |
$98.10
|
| Rate for Payer: Cigna Commercial |
$103.55
|
| Rate for Payer: Cigna Medicare |
$98.10
|
| Rate for Payer: Medicaid All Medicaid |
$100.28
|
| Rate for Payer: Medicare All Medicare |
$76.30
|
| Rate for Payer: Monida Allegiance |
$103.55
|
| Rate for Payer: Monida First Choice Health |
$105.73
|
| Rate for Payer: Monida Montana Health Co-op |
$103.55
|
| Rate for Payer: Monida PacificSource |
$103.55
|
|
|
PRO FEE OP INJ SI JOINT W/IMAGE 27096
|
Professional
|
Both
|
$82.00
|
|
|
Service Code
|
HCPCS 27096 GF
|
| Hospital Charge Code |
727096
|
|
Hospital Revenue Code
|
964
|
| Min. Negotiated Rate |
$57.40 |
| Max. Negotiated Rate |
$82.00 |
| Rate for Payer: Aetna Commercial |
$77.90
|
| Rate for Payer: Aetna Medicare |
$73.80
|
| Rate for Payer: BCBS MT CHIP |
$73.80
|
| Rate for Payer: BCBS MT Closed Plan Network |
$77.90
|
| Rate for Payer: BCBS MT HealthLink |
$73.80
|
| Rate for Payer: BCBS MT Medicare |
$73.80
|
| Rate for Payer: BCBS MT POS |
$77.90
|
| Rate for Payer: BCBS MT Traditional |
$82.00
|
| Rate for Payer: Cash Price |
$73.80
|
| Rate for Payer: Cigna Commercial |
$77.90
|
| Rate for Payer: Cigna Medicare |
$73.80
|
| Rate for Payer: Medicaid All Medicaid |
$75.44
|
| Rate for Payer: Medicare All Medicare |
$57.40
|
| Rate for Payer: Monida Allegiance |
$77.90
|
| Rate for Payer: Monida First Choice Health |
$79.54
|
| Rate for Payer: Monida Montana Health Co-op |
$77.90
|
| Rate for Payer: Monida PacificSource |
$77.90
|
|
|
PRO FEE OP INJ SPHENOPALGANG BLOC 64505
|
Professional
|
Both
|
$185.00
|
|
|
Service Code
|
HCPCS 64505
|
| Hospital Charge Code |
764505
|
|
Hospital Revenue Code
|
964
|
| Min. Negotiated Rate |
$129.50 |
| Max. Negotiated Rate |
$185.00 |
| Rate for Payer: Aetna Commercial |
$175.75
|
| Rate for Payer: Aetna Medicare |
$166.50
|
| Rate for Payer: BCBS MT CHIP |
$166.50
|
| Rate for Payer: BCBS MT Closed Plan Network |
$175.75
|
| Rate for Payer: BCBS MT HealthLink |
$166.50
|
| Rate for Payer: BCBS MT Medicare |
$166.50
|
| Rate for Payer: BCBS MT POS |
$175.75
|
| Rate for Payer: BCBS MT Traditional |
$185.00
|
| Rate for Payer: Cash Price |
$166.50
|
| Rate for Payer: Cigna Commercial |
$175.75
|
| Rate for Payer: Cigna Medicare |
$166.50
|
| Rate for Payer: Medicaid All Medicaid |
$170.20
|
| Rate for Payer: Medicare All Medicare |
$129.50
|
| Rate for Payer: Monida Allegiance |
$175.75
|
| Rate for Payer: Monida First Choice Health |
$179.45
|
| Rate for Payer: Monida Montana Health Co-op |
$175.75
|
| Rate for Payer: Monida PacificSource |
$175.75
|
|
|
PRO FEE OP INJ STELLATE GANG BLOCK 64510
|
Professional
|
Both
|
$391.00
|
|
|
Service Code
|
HCPCS 64510
|
| Hospital Charge Code |
764510
|
|
Hospital Revenue Code
|
964
|
| Min. Negotiated Rate |
$273.70 |
| Max. Negotiated Rate |
$391.00 |
| Rate for Payer: Aetna Commercial |
$371.45
|
| Rate for Payer: Aetna Medicare |
$351.90
|
| Rate for Payer: BCBS MT CHIP |
$351.90
|
| Rate for Payer: BCBS MT Closed Plan Network |
$371.45
|
| Rate for Payer: BCBS MT HealthLink |
$351.90
|
| Rate for Payer: BCBS MT Medicare |
$351.90
|
| Rate for Payer: BCBS MT POS |
$371.45
|
| Rate for Payer: BCBS MT Traditional |
$391.00
|
| Rate for Payer: Cash Price |
$351.90
|
| Rate for Payer: Cigna Commercial |
$371.45
|
| Rate for Payer: Cigna Medicare |
$351.90
|
| Rate for Payer: Medicaid All Medicaid |
$359.72
|
| Rate for Payer: Medicare All Medicare |
$273.70
|
| Rate for Payer: Monida Allegiance |
$371.45
|
| Rate for Payer: Monida First Choice Health |
$379.27
|
| Rate for Payer: Monida Montana Health Co-op |
$371.45
|
| Rate for Payer: Monida PacificSource |
$371.45
|
|
|
PRO FEE OP INJ SUPER HYPOGSTRC PLX 64517
|
Professional
|
Both
|
$373.00
|
|
|
Service Code
|
HCPCS 64517
|
| Hospital Charge Code |
764517
|
|
Hospital Revenue Code
|
964
|
| Min. Negotiated Rate |
$261.10 |
| Max. Negotiated Rate |
$373.00 |
| Rate for Payer: Aetna Commercial |
$354.35
|
| Rate for Payer: Aetna Medicare |
$335.70
|
| Rate for Payer: BCBS MT CHIP |
$335.70
|
| Rate for Payer: BCBS MT Closed Plan Network |
$354.35
|
| Rate for Payer: BCBS MT HealthLink |
$335.70
|
| Rate for Payer: BCBS MT Medicare |
$335.70
|
| Rate for Payer: BCBS MT POS |
$354.35
|
| Rate for Payer: BCBS MT Traditional |
$373.00
|
| Rate for Payer: Cash Price |
$335.70
|
| Rate for Payer: Cigna Commercial |
$354.35
|
| Rate for Payer: Cigna Medicare |
$335.70
|
| Rate for Payer: Medicaid All Medicaid |
$343.16
|
| Rate for Payer: Medicare All Medicare |
$261.10
|
| Rate for Payer: Monida Allegiance |
$354.35
|
| Rate for Payer: Monida First Choice Health |
$361.81
|
| Rate for Payer: Monida Montana Health Co-op |
$354.35
|
| Rate for Payer: Monida PacificSource |
$354.35
|
|
|
PRO FEE OP INJ SUPRASCAP NERVE 764418
|
Professional
|
Both
|
$240.00
|
|
|
Service Code
|
HCPCS 64418
|
| Hospital Charge Code |
764418
|
|
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 OP INJ TRANFOR C/T ADDTL 64480
|
Professional
|
Both
|
$268.00
|
|
|
Service Code
|
HCPCS 64480
|
| Hospital Charge Code |
764480
|
|
Hospital Revenue Code
|
964
|
| Min. Negotiated Rate |
$187.60 |
| Max. Negotiated Rate |
$268.00 |
| Rate for Payer: Aetna Commercial |
$254.60
|
| Rate for Payer: Aetna Medicare |
$241.20
|
| Rate for Payer: BCBS MT CHIP |
$241.20
|
| Rate for Payer: BCBS MT Closed Plan Network |
$254.60
|
| Rate for Payer: BCBS MT HealthLink |
$241.20
|
| Rate for Payer: BCBS MT Medicare |
$241.20
|
| Rate for Payer: BCBS MT POS |
$254.60
|
| Rate for Payer: BCBS MT Traditional |
$268.00
|
| Rate for Payer: Cash Price |
$241.20
|
| Rate for Payer: Cigna Commercial |
$254.60
|
| Rate for Payer: Cigna Medicare |
$241.20
|
| Rate for Payer: Medicaid All Medicaid |
$246.56
|
| Rate for Payer: Medicare All Medicare |
$187.60
|
| Rate for Payer: Monida Allegiance |
$254.60
|
| Rate for Payer: Monida First Choice Health |
$259.96
|
| Rate for Payer: Monida Montana Health Co-op |
$254.60
|
| Rate for Payer: Monida PacificSource |
$254.60
|
|
|
PRO FEE OP INJ TRANSFORA L/S 1 64483
|
Professional
|
Both
|
$704.00
|
|
|
Service Code
|
HCPCS 64483
|
| Hospital Charge Code |
764483
|
|
Hospital Revenue Code
|
964
|
| Min. Negotiated Rate |
$492.80 |
| Max. Negotiated Rate |
$704.00 |
| Rate for Payer: Aetna Commercial |
$668.80
|
| Rate for Payer: Aetna Medicare |
$633.60
|
| Rate for Payer: BCBS MT CHIP |
$633.60
|
| Rate for Payer: BCBS MT Closed Plan Network |
$668.80
|
| Rate for Payer: BCBS MT HealthLink |
$633.60
|
| Rate for Payer: BCBS MT Medicare |
$633.60
|
| Rate for Payer: BCBS MT POS |
$668.80
|
| Rate for Payer: BCBS MT Traditional |
$704.00
|
| Rate for Payer: Cash Price |
$633.60
|
| Rate for Payer: Cigna Commercial |
$668.80
|
| Rate for Payer: Cigna Medicare |
$633.60
|
| Rate for Payer: Medicaid All Medicaid |
$647.68
|
| Rate for Payer: Medicare All Medicare |
$492.80
|
| Rate for Payer: Monida Allegiance |
$668.80
|
| Rate for Payer: Monida First Choice Health |
$682.88
|
| Rate for Payer: Monida Montana Health Co-op |
$668.80
|
| Rate for Payer: Monida PacificSource |
$668.80
|
|
|
PRO FEE OP INSERTION PICC LINE 36569
|
Professional
|
Both
|
$457.00
|
|
|
Service Code
|
HCPCS 36569
|
| Hospital Charge Code |
736569
|
|
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 MAJOR JOINT INJ W/US 20611
|
Professional
|
Both
|
$282.20
|
|
|
Service Code
|
HCPCS 20611 GF
|
| Hospital Charge Code |
720611
|
|
Hospital Revenue Code
|
964
|
| Min. Negotiated Rate |
$197.54 |
| Max. Negotiated Rate |
$282.20 |
| Rate for Payer: Aetna Commercial |
$268.09
|
| Rate for Payer: Aetna Medicare |
$253.98
|
| Rate for Payer: BCBS MT CHIP |
$253.98
|
| Rate for Payer: BCBS MT Closed Plan Network |
$268.09
|
| Rate for Payer: BCBS MT HealthLink |
$253.98
|
| Rate for Payer: BCBS MT Medicare |
$253.98
|
| Rate for Payer: BCBS MT POS |
$268.09
|
| Rate for Payer: BCBS MT Traditional |
$282.20
|
| Rate for Payer: Cash Price |
$253.98
|
| Rate for Payer: Cigna Commercial |
$268.09
|
| Rate for Payer: Cigna Medicare |
$253.98
|
| Rate for Payer: Medicaid All Medicaid |
$259.62
|
| Rate for Payer: Medicare All Medicare |
$197.54
|
| Rate for Payer: Monida Allegiance |
$268.09
|
| Rate for Payer: Monida First Choice Health |
$273.73
|
| Rate for Payer: Monida Montana Health Co-op |
$268.09
|
| Rate for Payer: Monida PacificSource |
$268.09
|
|
|
PRO FEE OPO HIGH
|
Professional
|
Both
|
$347.00
|
|
|
Service Code
|
HCPCS 99223 AQ
|
| Hospital Charge Code |
799220
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$242.90 |
| Max. Negotiated Rate |
$336.59 |
| Rate for Payer: Aetna Commercial |
$329.65
|
| Rate for Payer: Aetna Medicare |
$312.30
|
| Rate for Payer: Cash Price |
$312.30
|
| Rate for Payer: Medicaid All Medicaid |
$319.24
|
| Rate for Payer: Medicare All Medicare |
$242.90
|
| Rate for Payer: Monida Allegiance |
$329.65
|
| Rate for Payer: Monida First Choice Health |
$336.59
|
| Rate for Payer: Monida Montana Health Co-op |
$329.65
|
| Rate for Payer: Monida PacificSource |
$329.65
|
|
|
PRO FEE OPO LOW (99221)
|
Professional
|
Both
|
$210.00
|
|
|
Service Code
|
HCPCS 99221 AQ
|
| Hospital Charge Code |
799218
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$147.00 |
| Max. Negotiated Rate |
$203.70 |
| Rate for Payer: Aetna Commercial |
$199.50
|
| Rate for Payer: Aetna Medicare |
$189.00
|
| Rate for Payer: Cash Price |
$189.00
|
| Rate for Payer: Medicaid All Medicaid |
$193.20
|
| Rate for Payer: Medicare All Medicare |
$147.00
|
| Rate for Payer: Monida Allegiance |
$199.50
|
| Rate for Payer: Monida First Choice Health |
$203.70
|
| Rate for Payer: Monida Montana Health Co-op |
$199.50
|
| Rate for Payer: Monida PacificSource |
$199.50
|
|
|
PRO FEE OPO MODERATE
|
Professional
|
Both
|
$284.00
|
|
|
Service Code
|
HCPCS 99222 AQ
|
| Hospital Charge Code |
799219
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$198.80 |
| Max. Negotiated Rate |
$275.48 |
| Rate for Payer: Aetna Commercial |
$269.80
|
| Rate for Payer: Aetna Medicare |
$255.60
|
| Rate for Payer: Cash Price |
$255.60
|
| Rate for Payer: Medicaid All Medicaid |
$261.28
|
| Rate for Payer: Medicare All Medicare |
$198.80
|
| Rate for Payer: Monida Allegiance |
$269.80
|
| Rate for Payer: Monida First Choice Health |
$275.48
|
| Rate for Payer: Monida Montana Health Co-op |
$269.80
|
| Rate for Payer: Monida PacificSource |
$269.80
|
|
|
PRO FEE OPO SAME DAY ADMIT/D/CLOW
|
Professional
|
Both
|
$278.00
|
|
|
Service Code
|
HCPCS 99234 AQ
|
| Hospital Charge Code |
739234
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$194.60 |
| Max. Negotiated Rate |
$269.66 |
| Rate for Payer: Aetna Commercial |
$264.10
|
| Rate for Payer: Aetna Medicare |
$250.20
|
| Rate for Payer: Cash Price |
$250.20
|
| Rate for Payer: Medicaid All Medicaid |
$255.76
|
| Rate for Payer: Medicare All Medicare |
$194.60
|
| Rate for Payer: Monida Allegiance |
$264.10
|
| Rate for Payer: Monida First Choice Health |
$269.66
|
| Rate for Payer: Monida Montana Health Co-op |
$264.10
|
| Rate for Payer: Monida PacificSource |
$264.10
|
|
|
PRO FEE OPO SAME DAY ADMIT HIGH
|
Professional
|
Both
|
$457.00
|
|
|
Service Code
|
HCPCS 99236 AQ
|
| Hospital Charge Code |
799236
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$319.90 |
| Max. Negotiated Rate |
$443.29 |
| Rate for Payer: Aetna Commercial |
$434.15
|
| Rate for Payer: Aetna Medicare |
$411.30
|
| Rate for Payer: Cash Price |
$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 OPO SAME DAY ADMIT MOD
|
Professional
|
Both
|
$352.00
|
|
|
Service Code
|
HCPCS 99235 AQ
|
| Hospital Charge Code |
739235
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$246.40 |
| Max. Negotiated Rate |
$341.44 |
| Rate for Payer: Aetna Commercial |
$334.40
|
| Rate for Payer: Aetna Medicare |
$316.80
|
| Rate for Payer: Cash Price |
$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
|
|
|
PRO FEE OPO SEPARATE DAY DISCHARGE 30MI
|
Professional
|
Both
|
$152.00
|
|
|
Service Code
|
HCPCS 99238 AQ
|
| Hospital Charge Code |
799238
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$106.40 |
| Max. Negotiated Rate |
$147.44 |
| Rate for Payer: Aetna Commercial |
$144.40
|
| Rate for Payer: Aetna Medicare |
$136.80
|
| Rate for Payer: Cash Price |
$136.80
|
| Rate for Payer: Medicaid All Medicaid |
$139.84
|
| Rate for Payer: Medicare All Medicare |
$106.40
|
| Rate for Payer: Monida Allegiance |
$144.40
|
| Rate for Payer: Monida First Choice Health |
$147.44
|
| Rate for Payer: Monida Montana Health Co-op |
$144.40
|
| Rate for Payer: Monida PacificSource |
$144.40
|
|
|
PRO FEE OPO SEPARATE DAY DISCHARGE>30MI
|
Professional
|
Both
|
$226.00
|
|
|
Service Code
|
HCPCS 99239 AQ
|
| Hospital Charge Code |
799239
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$158.20 |
| Max. Negotiated Rate |
$219.22 |
| Rate for Payer: Aetna Commercial |
$214.70
|
| Rate for Payer: Aetna Medicare |
$203.40
|
| Rate for Payer: Cash Price |
$203.40
|
| Rate for Payer: Medicaid All Medicaid |
$207.92
|
| Rate for Payer: Medicare All Medicare |
$158.20
|
| Rate for Payer: Monida Allegiance |
$214.70
|
| Rate for Payer: Monida First Choice Health |
$219.22
|
| Rate for Payer: Monida Montana Health Co-op |
$214.70
|
| Rate for Payer: Monida PacificSource |
$214.70
|
|
|
PRO FEE OPO SEPARATE DAY DISCHARGE 99217
|
Professional
|
Both
|
$189.00
|
|
|
Service Code
|
HCPCS 99217 AQ
|
| Hospital Charge Code |
799217
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$132.30 |
| Max. Negotiated Rate |
$183.33 |
| Rate for Payer: Aetna Commercial |
$179.55
|
| Rate for Payer: Aetna Medicare |
$170.10
|
| Rate for Payer: Cash Price |
$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 PMGT INJ TRIGEM NRV BLC 64400
|
Professional
|
Both
|
$149.00
|
|
|
Service Code
|
HCPCS 64400
|
| Hospital Charge Code |
764400
|
|
Hospital Revenue Code
|
964
|
| 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 OP UNLISTED PROCEDURE 64999
|
Professional
|
Both
|
$449.00
|
|
|
Service Code
|
HCPCS 64999
|
| Hospital Charge Code |
764999
|
|
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 PARAVERT SYMP BLOCK T/L 64520
|
Professional
|
Both
|
$525.00
|
|
|
Service Code
|
HCPCS 64520
|
| Hospital Charge Code |
764520
|
|
Hospital Revenue Code
|
964
|
| Min. Negotiated Rate |
$367.50 |
| Max. Negotiated Rate |
$525.00 |
| Rate for Payer: Aetna Commercial |
$498.75
|
| Rate for Payer: Aetna Medicare |
$472.50
|
| Rate for Payer: BCBS MT CHIP |
$472.50
|
| Rate for Payer: BCBS MT Closed Plan Network |
$498.75
|
| Rate for Payer: BCBS MT HealthLink |
$472.50
|
| Rate for Payer: BCBS MT Medicare |
$472.50
|
| Rate for Payer: BCBS MT POS |
$498.75
|
| Rate for Payer: BCBS MT Traditional |
$525.00
|
| Rate for Payer: Cash Price |
$472.50
|
| Rate for Payer: Cigna Commercial |
$498.75
|
| Rate for Payer: Cigna Medicare |
$472.50
|
| Rate for Payer: Medicaid All Medicaid |
$483.00
|
| Rate for Payer: Medicare All Medicare |
$367.50
|
| Rate for Payer: Monida Allegiance |
$498.75
|
| Rate for Payer: Monida First Choice Health |
$509.25
|
| Rate for Payer: Monida Montana Health Co-op |
$498.75
|
| Rate for Payer: Monida PacificSource |
$498.75
|
|
