|
PROFEE ECHO REAL TIME IMAGING
|
Professional
|
Both
|
$118.00
|
|
|
Service Code
|
HCPCS 76506 26
|
| Hospital Charge Code |
50002396
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$82.60 |
| Max. Negotiated Rate |
$114.46 |
| Rate for Payer: Aetna Commercial |
$112.10
|
| Rate for Payer: Aetna Medicare |
$106.20
|
| Rate for Payer: Cash Price |
$106.20
|
| Rate for Payer: Medicaid All Medicaid |
$108.56
|
| Rate for Payer: Medicare All Medicare |
$82.60
|
| Rate for Payer: Monida Allegiance |
$112.10
|
| Rate for Payer: Monida First Choice Health |
$114.46
|
| Rate for Payer: Monida Montana Health Co-op |
$112.10
|
| Rate for Payer: Monida PacificSource |
$112.10
|
|
|
PROFEE EGD 43235
|
Professional
|
Both
|
$404.00
|
|
|
Service Code
|
HCPCS 43235
|
| Hospital Charge Code |
584000
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$282.80 |
| Max. Negotiated Rate |
$391.88 |
| Rate for Payer: Aetna Commercial |
$383.80
|
| Rate for Payer: Aetna Medicare |
$363.60
|
| Rate for Payer: Cash Price |
$363.60
|
| Rate for Payer: Medicaid All Medicaid |
$371.68
|
| Rate for Payer: Medicare All Medicare |
$282.80
|
| Rate for Payer: Monida Allegiance |
$383.80
|
| Rate for Payer: Monida First Choice Health |
$391.88
|
| Rate for Payer: Monida Montana Health Co-op |
$383.80
|
| Rate for Payer: Monida PacificSource |
$383.80
|
|
|
PROFEE EGD W/ BIOPSY 43239
|
Professional
|
Both
|
$454.00
|
|
|
Service Code
|
HCPCS 43239
|
| Hospital Charge Code |
5840001
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$317.80 |
| Max. Negotiated Rate |
$440.38 |
| Rate for Payer: Aetna Commercial |
$431.30
|
| Rate for Payer: Aetna Medicare |
$408.60
|
| Rate for Payer: Cash Price |
$408.60
|
| Rate for Payer: Medicaid All Medicaid |
$417.68
|
| Rate for Payer: Medicare All Medicare |
$317.80
|
| Rate for Payer: Monida Allegiance |
$431.30
|
| Rate for Payer: Monida First Choice Health |
$440.38
|
| Rate for Payer: Monida Montana Health Co-op |
$431.30
|
| Rate for Payer: Monida PacificSource |
$431.30
|
|
|
PRO FEE EKG 12 LEAD
|
Professional
|
Both
|
$18.00
|
|
|
Service Code
|
HCPCS 93010 AQ
|
| Hospital Charge Code |
793010
|
|
Hospital Revenue Code
|
985
|
| Min. Negotiated Rate |
$12.60 |
| Max. Negotiated Rate |
$17.46 |
| Rate for Payer: Aetna Commercial |
$17.10
|
| Rate for Payer: Aetna Medicare |
$16.20
|
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Medicaid All Medicaid |
$16.56
|
| Rate for Payer: Medicare All Medicare |
$12.60
|
| Rate for Payer: Monida Allegiance |
$17.10
|
| Rate for Payer: Monida First Choice Health |
$17.46
|
| Rate for Payer: Monida Montana Health Co-op |
$17.10
|
| Rate for Payer: Monida PacificSource |
$17.10
|
|
|
PRO FEE EPISTAXIS, COMPLEX
|
Professional
|
Both
|
$99.00
|
|
|
Service Code
|
HCPCS 30903
|
| Hospital Charge Code |
730903
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$69.30 |
| Max. Negotiated Rate |
$99.00 |
| Rate for Payer: Aetna Commercial |
$94.05
|
| Rate for Payer: Aetna Medicare |
$89.10
|
| Rate for Payer: BCBS MT CHIP |
$89.10
|
| Rate for Payer: BCBS MT Closed Plan Network |
$94.05
|
| Rate for Payer: BCBS MT HealthLink |
$89.10
|
| Rate for Payer: BCBS MT Medicare |
$89.10
|
| Rate for Payer: BCBS MT POS |
$94.05
|
| Rate for Payer: BCBS MT Traditional |
$99.00
|
| Rate for Payer: Cash Price |
$89.10
|
| Rate for Payer: Cigna Commercial |
$94.05
|
| Rate for Payer: Cigna Medicare |
$89.10
|
| Rate for Payer: Medicaid All Medicaid |
$91.08
|
| Rate for Payer: Medicare All Medicare |
$69.30
|
| Rate for Payer: Monida Allegiance |
$94.05
|
| Rate for Payer: Monida First Choice Health |
$96.03
|
| Rate for Payer: Monida Montana Health Co-op |
$94.05
|
| Rate for Payer: Monida PacificSource |
$94.05
|
|
|
PRO FEE EPISTAXIS, INITIAL
|
Professional
|
Both
|
$89.00
|
|
|
Service Code
|
HCPCS 30905
|
| Hospital Charge Code |
730905
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$62.30 |
| Max. Negotiated Rate |
$89.00 |
| Rate for Payer: Aetna Commercial |
$84.55
|
| Rate for Payer: Aetna Medicare |
$80.10
|
| Rate for Payer: BCBS MT CHIP |
$80.10
|
| Rate for Payer: BCBS MT Closed Plan Network |
$84.55
|
| Rate for Payer: BCBS MT HealthLink |
$80.10
|
| Rate for Payer: BCBS MT Medicare |
$80.10
|
| Rate for Payer: BCBS MT POS |
$84.55
|
| Rate for Payer: BCBS MT Traditional |
$89.00
|
| Rate for Payer: Cash Price |
$80.10
|
| Rate for Payer: Cigna Commercial |
$84.55
|
| Rate for Payer: Cigna Medicare |
$80.10
|
| Rate for Payer: Medicaid All Medicaid |
$81.88
|
| Rate for Payer: Medicare All Medicare |
$62.30
|
| Rate for Payer: Monida Allegiance |
$84.55
|
| Rate for Payer: Monida First Choice Health |
$86.33
|
| Rate for Payer: Monida Montana Health Co-op |
$84.55
|
| Rate for Payer: Monida PacificSource |
$84.55
|
|
|
PRO FEE EPISTAXIS, SIMPLE
|
Professional
|
Both
|
$89.00
|
|
|
Service Code
|
HCPCS 30901
|
| Hospital Charge Code |
730901
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$62.30 |
| Max. Negotiated Rate |
$89.00 |
| Rate for Payer: Aetna Commercial |
$84.55
|
| Rate for Payer: Aetna Medicare |
$80.10
|
| Rate for Payer: BCBS MT CHIP |
$80.10
|
| Rate for Payer: BCBS MT Closed Plan Network |
$84.55
|
| Rate for Payer: BCBS MT HealthLink |
$80.10
|
| Rate for Payer: BCBS MT Medicare |
$80.10
|
| Rate for Payer: BCBS MT POS |
$84.55
|
| Rate for Payer: BCBS MT Traditional |
$89.00
|
| Rate for Payer: Cash Price |
$80.10
|
| Rate for Payer: Cigna Commercial |
$84.55
|
| Rate for Payer: Cigna Medicare |
$80.10
|
| Rate for Payer: Medicaid All Medicaid |
$81.88
|
| Rate for Payer: Medicare All Medicare |
$62.30
|
| Rate for Payer: Monida Allegiance |
$84.55
|
| Rate for Payer: Monida First Choice Health |
$86.33
|
| Rate for Payer: Monida Montana Health Co-op |
$84.55
|
| Rate for Payer: Monida PacificSource |
$84.55
|
|
|
PRO FEE ER APPLICATION OF SHORT LEG SPLI
|
Professional
|
Both
|
$262.00
|
|
|
Service Code
|
HCPCS 29515
|
| Hospital Charge Code |
7229515
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$183.40 |
| Max. Negotiated Rate |
$262.00 |
| Rate for Payer: Aetna Commercial |
$248.90
|
| Rate for Payer: Aetna Medicare |
$235.80
|
| Rate for Payer: BCBS MT CHIP |
$235.80
|
| Rate for Payer: BCBS MT Closed Plan Network |
$248.90
|
| Rate for Payer: BCBS MT HealthLink |
$235.80
|
| Rate for Payer: BCBS MT Medicare |
$235.80
|
| Rate for Payer: BCBS MT POS |
$248.90
|
| Rate for Payer: BCBS MT Traditional |
$262.00
|
| Rate for Payer: Cash Price |
$235.80
|
| Rate for Payer: Cigna Commercial |
$248.90
|
| Rate for Payer: Cigna Medicare |
$235.80
|
| Rate for Payer: Medicaid All Medicaid |
$241.04
|
| Rate for Payer: Medicare All Medicare |
$183.40
|
| Rate for Payer: Monida Allegiance |
$248.90
|
| Rate for Payer: Monida First Choice Health |
$254.14
|
| Rate for Payer: Monida Montana Health Co-op |
$248.90
|
| Rate for Payer: Monida PacificSource |
$248.90
|
|
|
PRO FEE ER APPLICATION SPLINT LONG 29105
|
Professional
|
Both
|
$214.00
|
|
|
Service Code
|
HCPCS 29105
|
| Hospital Charge Code |
729105
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$149.80 |
| Max. Negotiated Rate |
$214.00 |
| Rate for Payer: Aetna Commercial |
$203.30
|
| Rate for Payer: Aetna Medicare |
$192.60
|
| Rate for Payer: BCBS MT CHIP |
$192.60
|
| Rate for Payer: BCBS MT Closed Plan Network |
$203.30
|
| Rate for Payer: BCBS MT HealthLink |
$192.60
|
| Rate for Payer: BCBS MT Medicare |
$192.60
|
| Rate for Payer: BCBS MT POS |
$203.30
|
| Rate for Payer: BCBS MT Traditional |
$214.00
|
| Rate for Payer: Cash Price |
$192.60
|
| Rate for Payer: Cigna Commercial |
$203.30
|
| Rate for Payer: Cigna Medicare |
$192.60
|
| Rate for Payer: Medicaid All Medicaid |
$196.88
|
| Rate for Payer: Medicare All Medicare |
$149.80
|
| Rate for Payer: Monida Allegiance |
$203.30
|
| Rate for Payer: Monida First Choice Health |
$207.58
|
| Rate for Payer: Monida Montana Health Co-op |
$203.30
|
| Rate for Payer: Monida PacificSource |
$203.30
|
|
|
PRO FEE ER APPL OF LONG LEG SPLINT
|
Professional
|
Both
|
$278.00
|
|
|
Service Code
|
HCPCS 29505
|
| Hospital Charge Code |
7229505
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$194.60 |
| Max. Negotiated Rate |
$278.00 |
| Rate for Payer: Aetna Commercial |
$264.10
|
| Rate for Payer: Aetna Medicare |
$250.20
|
| Rate for Payer: BCBS MT CHIP |
$250.20
|
| Rate for Payer: BCBS MT Closed Plan Network |
$264.10
|
| Rate for Payer: BCBS MT HealthLink |
$250.20
|
| Rate for Payer: BCBS MT Medicare |
$250.20
|
| Rate for Payer: BCBS MT POS |
$264.10
|
| Rate for Payer: BCBS MT Traditional |
$278.00
|
| Rate for Payer: Cash Price |
$250.20
|
| Rate for Payer: Cigna Commercial |
$264.10
|
| Rate for Payer: Cigna Medicare |
$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 ER BRIEF 99281
|
Professional
|
Both
|
$35.00
|
|
|
Service Code
|
HCPCS 99281 AQ
|
| Hospital Charge Code |
799281
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$24.50 |
| Max. Negotiated Rate |
$35.00 |
| Rate for Payer: Aetna Commercial |
$33.25
|
| Rate for Payer: Aetna Medicare |
$31.50
|
| Rate for Payer: BCBS MT CHIP |
$31.50
|
| Rate for Payer: BCBS MT Closed Plan Network |
$33.25
|
| Rate for Payer: BCBS MT HealthLink |
$31.50
|
| Rate for Payer: BCBS MT Medicare |
$31.50
|
| Rate for Payer: BCBS MT POS |
$33.25
|
| Rate for Payer: BCBS MT Traditional |
$35.00
|
| Rate for Payer: Cash Price |
$31.50
|
| Rate for Payer: Cigna Commercial |
$33.25
|
| Rate for Payer: Cigna Medicare |
$31.50
|
| Rate for Payer: Medicaid All Medicaid |
$32.20
|
| Rate for Payer: Medicare All Medicare |
$24.50
|
| Rate for Payer: Monida Allegiance |
$33.25
|
| Rate for Payer: Monida First Choice Health |
$33.95
|
| Rate for Payer: Monida Montana Health Co-op |
$33.25
|
| Rate for Payer: Monida PacificSource |
$33.25
|
|
|
PRO FEE ER CARDIOPULMONARY RESUSC 92950
|
Professional
|
Both
|
$316.00
|
|
|
Service Code
|
HCPCS 92950
|
| Hospital Charge Code |
792950
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$221.20 |
| Max. Negotiated Rate |
$316.00 |
| Rate for Payer: Aetna Commercial |
$300.20
|
| Rate for Payer: Aetna Medicare |
$284.40
|
| Rate for Payer: BCBS MT CHIP |
$284.40
|
| Rate for Payer: BCBS MT Closed Plan Network |
$300.20
|
| Rate for Payer: BCBS MT HealthLink |
$284.40
|
| Rate for Payer: BCBS MT Medicare |
$284.40
|
| Rate for Payer: BCBS MT POS |
$300.20
|
| Rate for Payer: BCBS MT Traditional |
$316.00
|
| Rate for Payer: Cash Price |
$284.40
|
| Rate for Payer: Cigna Commercial |
$300.20
|
| Rate for Payer: Cigna Medicare |
$284.40
|
| Rate for Payer: Medicaid All Medicaid |
$290.72
|
| Rate for Payer: Medicare All Medicare |
$221.20
|
| Rate for Payer: Monida Allegiance |
$300.20
|
| Rate for Payer: Monida First Choice Health |
$306.52
|
| Rate for Payer: Monida Montana Health Co-op |
$300.20
|
| Rate for Payer: Monida PacificSource |
$300.20
|
|
|
PRO FEE ER CLOSED TRT NOSE FX W/O STAB
|
Professional
|
Both
|
$312.00
|
|
|
Service Code
|
HCPCS 21315
|
| Hospital Charge Code |
721315
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$218.40 |
| Max. Negotiated Rate |
$312.00 |
| Rate for Payer: Aetna Commercial |
$296.40
|
| Rate for Payer: Aetna Medicare |
$280.80
|
| Rate for Payer: BCBS MT CHIP |
$280.80
|
| Rate for Payer: BCBS MT Closed Plan Network |
$296.40
|
| Rate for Payer: BCBS MT HealthLink |
$280.80
|
| Rate for Payer: BCBS MT Medicare |
$280.80
|
| Rate for Payer: BCBS MT POS |
$296.40
|
| Rate for Payer: BCBS MT Traditional |
$312.00
|
| Rate for Payer: Cash Price |
$280.80
|
| Rate for Payer: Cigna Commercial |
$296.40
|
| Rate for Payer: Cigna Medicare |
$280.80
|
| Rate for Payer: Medicaid All Medicaid |
$287.04
|
| Rate for Payer: Medicare All Medicare |
$218.40
|
| Rate for Payer: Monida Allegiance |
$296.40
|
| Rate for Payer: Monida First Choice Health |
$302.64
|
| Rate for Payer: Monida Montana Health Co-op |
$296.40
|
| Rate for Payer: Monida PacificSource |
$296.40
|
|
|
PRO FEE ER COMPREHENSIVE 99285
|
Professional
|
Both
|
$462.00
|
|
|
Service Code
|
HCPCS 99285 AQ
|
| Hospital Charge Code |
799285
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$323.40 |
| Max. Negotiated Rate |
$462.00 |
| Rate for Payer: Aetna Commercial |
$438.90
|
| Rate for Payer: Aetna Medicare |
$415.80
|
| Rate for Payer: BCBS MT CHIP |
$415.80
|
| Rate for Payer: BCBS MT Closed Plan Network |
$438.90
|
| Rate for Payer: BCBS MT HealthLink |
$415.80
|
| Rate for Payer: BCBS MT Medicare |
$415.80
|
| Rate for Payer: BCBS MT POS |
$438.90
|
| Rate for Payer: BCBS MT Traditional |
$462.00
|
| Rate for Payer: Cash Price |
$415.80
|
| Rate for Payer: Cigna Commercial |
$438.90
|
| Rate for Payer: Cigna Medicare |
$415.80
|
| Rate for Payer: Medicaid All Medicaid |
$425.04
|
| Rate for Payer: Medicare All Medicare |
$323.40
|
| Rate for Payer: Monida Allegiance |
$438.90
|
| Rate for Payer: Monida First Choice Health |
$448.14
|
| Rate for Payer: Monida Montana Health Co-op |
$438.90
|
| Rate for Payer: Monida PacificSource |
$438.90
|
|
|
PRO FEE ER CRITICAL CARE 1HR 99291
|
Professional
|
Both
|
$633.00
|
|
|
Service Code
|
HCPCS 99291 AQ
|
| Hospital Charge Code |
799291
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$443.10 |
| Max. Negotiated Rate |
$633.00 |
| Rate for Payer: Aetna Commercial |
$601.35
|
| Rate for Payer: Aetna Medicare |
$569.70
|
| Rate for Payer: BCBS MT CHIP |
$569.70
|
| Rate for Payer: BCBS MT Closed Plan Network |
$601.35
|
| Rate for Payer: BCBS MT HealthLink |
$569.70
|
| Rate for Payer: BCBS MT Medicare |
$569.70
|
| Rate for Payer: BCBS MT POS |
$601.35
|
| Rate for Payer: BCBS MT Traditional |
$633.00
|
| Rate for Payer: Cash Price |
$569.70
|
| Rate for Payer: Cigna Commercial |
$601.35
|
| Rate for Payer: Cigna Medicare |
$569.70
|
| Rate for Payer: Medicaid All Medicaid |
$582.36
|
| Rate for Payer: Medicare All Medicare |
$443.10
|
| Rate for Payer: Monida Allegiance |
$601.35
|
| Rate for Payer: Monida First Choice Health |
$614.01
|
| Rate for Payer: Monida Montana Health Co-op |
$601.35
|
| Rate for Payer: Monida PacificSource |
$601.35
|
|
|
PRO FEE ER CRITICAL CARE E ADD 30m 99292
|
Professional
|
Both
|
$316.00
|
|
|
Service Code
|
HCPCS 99292 AQ
|
| Hospital Charge Code |
799292
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$221.20 |
| Max. Negotiated Rate |
$316.00 |
| Rate for Payer: Aetna Commercial |
$300.20
|
| Rate for Payer: Aetna Medicare |
$284.40
|
| Rate for Payer: BCBS MT CHIP |
$284.40
|
| Rate for Payer: BCBS MT Closed Plan Network |
$300.20
|
| Rate for Payer: BCBS MT HealthLink |
$284.40
|
| Rate for Payer: BCBS MT Medicare |
$284.40
|
| Rate for Payer: BCBS MT POS |
$300.20
|
| Rate for Payer: BCBS MT Traditional |
$316.00
|
| Rate for Payer: Cash Price |
$284.40
|
| Rate for Payer: Cigna Commercial |
$300.20
|
| Rate for Payer: Cigna Medicare |
$284.40
|
| Rate for Payer: Medicaid All Medicaid |
$290.72
|
| Rate for Payer: Medicare All Medicare |
$221.20
|
| Rate for Payer: Monida Allegiance |
$300.20
|
| Rate for Payer: Monida First Choice Health |
$306.52
|
| Rate for Payer: Monida Montana Health Co-op |
$300.20
|
| Rate for Payer: Monida PacificSource |
$300.20
|
|
|
PRO FEE ER EXTENDED 99284
|
Professional
|
Both
|
$313.00
|
|
|
Service Code
|
HCPCS 99284 AQ
|
| Hospital Charge Code |
799284
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$219.10 |
| Max. Negotiated Rate |
$313.00 |
| Rate for Payer: Aetna Commercial |
$297.35
|
| Rate for Payer: Aetna Medicare |
$281.70
|
| Rate for Payer: BCBS MT CHIP |
$281.70
|
| Rate for Payer: BCBS MT Closed Plan Network |
$297.35
|
| Rate for Payer: BCBS MT HealthLink |
$281.70
|
| Rate for Payer: BCBS MT Medicare |
$281.70
|
| Rate for Payer: BCBS MT POS |
$297.35
|
| Rate for Payer: BCBS MT Traditional |
$313.00
|
| Rate for Payer: Cash Price |
$281.70
|
| Rate for Payer: Cigna Commercial |
$297.35
|
| Rate for Payer: Cigna Medicare |
$281.70
|
| Rate for Payer: Medicaid All Medicaid |
$287.96
|
| Rate for Payer: Medicare All Medicare |
$219.10
|
| Rate for Payer: Monida Allegiance |
$297.35
|
| Rate for Payer: Monida First Choice Health |
$303.61
|
| Rate for Payer: Monida Montana Health Co-op |
$297.35
|
| Rate for Payer: Monida PacificSource |
$297.35
|
|
|
PRO FEE ER INTERMEDIATE 99283
|
Professional
|
Both
|
$167.00
|
|
|
Service Code
|
HCPCS 99283 AQ
|
| Hospital Charge Code |
799283
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$116.90 |
| Max. Negotiated Rate |
$167.00 |
| Rate for Payer: Aetna Commercial |
$158.65
|
| Rate for Payer: Aetna Medicare |
$150.30
|
| Rate for Payer: BCBS MT CHIP |
$150.30
|
| Rate for Payer: BCBS MT Closed Plan Network |
$158.65
|
| Rate for Payer: BCBS MT HealthLink |
$150.30
|
| Rate for Payer: BCBS MT Medicare |
$150.30
|
| Rate for Payer: BCBS MT POS |
$158.65
|
| Rate for Payer: BCBS MT Traditional |
$167.00
|
| Rate for Payer: Cash Price |
$150.30
|
| Rate for Payer: Cigna Commercial |
$158.65
|
| Rate for Payer: Cigna Medicare |
$150.30
|
| Rate for Payer: Medicaid All Medicaid |
$153.64
|
| Rate for Payer: Medicare All Medicare |
$116.90
|
| Rate for Payer: Monida Allegiance |
$158.65
|
| Rate for Payer: Monida First Choice Health |
$161.99
|
| Rate for Payer: Monida Montana Health Co-op |
$158.65
|
| Rate for Payer: Monida PacificSource |
$158.65
|
|
|
PRO FEE ER INTUBATION ENDOTRACHEAL 31500
|
Professional
|
Both
|
$316.00
|
|
|
Service Code
|
HCPCS 31500
|
| Hospital Charge Code |
731500
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$221.20 |
| Max. Negotiated Rate |
$316.00 |
| Rate for Payer: Aetna Commercial |
$300.20
|
| Rate for Payer: Aetna Medicare |
$284.40
|
| Rate for Payer: BCBS MT CHIP |
$284.40
|
| Rate for Payer: BCBS MT Closed Plan Network |
$300.20
|
| Rate for Payer: BCBS MT HealthLink |
$284.40
|
| Rate for Payer: BCBS MT Medicare |
$284.40
|
| Rate for Payer: BCBS MT POS |
$300.20
|
| Rate for Payer: BCBS MT Traditional |
$316.00
|
| Rate for Payer: Cash Price |
$284.40
|
| Rate for Payer: Cigna Commercial |
$300.20
|
| Rate for Payer: Cigna Medicare |
$284.40
|
| Rate for Payer: Medicaid All Medicaid |
$290.72
|
| Rate for Payer: Medicare All Medicare |
$221.20
|
| Rate for Payer: Monida Allegiance |
$300.20
|
| Rate for Payer: Monida First Choice Health |
$306.52
|
| Rate for Payer: Monida Montana Health Co-op |
$300.20
|
| Rate for Payer: Monida PacificSource |
$300.20
|
|
|
PRO FEE ER LIMITED 99282
|
Professional
|
Both
|
$129.00
|
|
|
Service Code
|
HCPCS 99282 AQ
|
| Hospital Charge Code |
799282
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$90.30 |
| Max. Negotiated Rate |
$129.00 |
| Rate for Payer: Aetna Commercial |
$122.55
|
| Rate for Payer: Aetna Medicare |
$116.10
|
| Rate for Payer: BCBS MT CHIP |
$116.10
|
| Rate for Payer: BCBS MT Closed Plan Network |
$122.55
|
| Rate for Payer: BCBS MT HealthLink |
$116.10
|
| Rate for Payer: BCBS MT Medicare |
$116.10
|
| Rate for Payer: BCBS MT POS |
$122.55
|
| Rate for Payer: BCBS MT Traditional |
$129.00
|
| Rate for Payer: Cash Price |
$116.10
|
| Rate for Payer: Cigna Commercial |
$122.55
|
| Rate for Payer: Cigna Medicare |
$116.10
|
| Rate for Payer: Medicaid All Medicaid |
$118.68
|
| Rate for Payer: Medicare All Medicare |
$90.30
|
| Rate for Payer: Monida Allegiance |
$122.55
|
| Rate for Payer: Monida First Choice Health |
$125.13
|
| Rate for Payer: Monida Montana Health Co-op |
$122.55
|
| Rate for Payer: Monida PacificSource |
$122.55
|
|
|
PRO FEE ER OP INJ TRIGEM NRV BLC 64400
|
Professional
|
Both
|
$271.00
|
|
|
Service Code
|
HCPCS 64400
|
| Hospital Charge Code |
764401
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$189.70 |
| Max. Negotiated Rate |
$271.00 |
| Rate for Payer: Aetna Commercial |
$257.45
|
| Rate for Payer: Aetna Medicare |
$243.90
|
| Rate for Payer: BCBS MT CHIP |
$243.90
|
| Rate for Payer: BCBS MT Closed Plan Network |
$257.45
|
| Rate for Payer: BCBS MT HealthLink |
$243.90
|
| Rate for Payer: BCBS MT Medicare |
$243.90
|
| Rate for Payer: BCBS MT POS |
$257.45
|
| Rate for Payer: BCBS MT Traditional |
$271.00
|
| Rate for Payer: Cash Price |
$243.90
|
| Rate for Payer: Cigna Commercial |
$257.45
|
| Rate for Payer: Cigna Medicare |
$243.90
|
| Rate for Payer: Medicaid All Medicaid |
$249.32
|
| Rate for Payer: Medicare All Medicare |
$189.70
|
| Rate for Payer: Monida Allegiance |
$257.45
|
| Rate for Payer: Monida First Choice Health |
$262.87
|
| Rate for Payer: Monida Montana Health Co-op |
$257.45
|
| Rate for Payer: Monida PacificSource |
$257.45
|
|
|
PRO FEE ER REMOVAL FB-INTRANASAL (30300)
|
Professional
|
Both
|
$316.00
|
|
|
Service Code
|
HCPCS 30300
|
| Hospital Charge Code |
730300
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$221.20 |
| Max. Negotiated Rate |
$316.00 |
| Rate for Payer: Aetna Commercial |
$300.20
|
| Rate for Payer: Aetna Medicare |
$284.40
|
| Rate for Payer: BCBS MT CHIP |
$284.40
|
| Rate for Payer: BCBS MT Closed Plan Network |
$300.20
|
| Rate for Payer: BCBS MT HealthLink |
$284.40
|
| Rate for Payer: BCBS MT Medicare |
$284.40
|
| Rate for Payer: BCBS MT POS |
$300.20
|
| Rate for Payer: BCBS MT Traditional |
$316.00
|
| Rate for Payer: Cash Price |
$284.40
|
| Rate for Payer: Cigna Commercial |
$300.20
|
| Rate for Payer: Cigna Medicare |
$284.40
|
| Rate for Payer: Medicaid All Medicaid |
$290.72
|
| Rate for Payer: Medicare All Medicare |
$221.20
|
| Rate for Payer: Monida Allegiance |
$300.20
|
| Rate for Payer: Monida First Choice Health |
$306.52
|
| Rate for Payer: Monida Montana Health Co-op |
$300.20
|
| Rate for Payer: Monida PacificSource |
$300.20
|
|
|
PRO FEE ER STRAPPING OF WRIST
|
Professional
|
Both
|
$96.00
|
|
|
Service Code
|
HCPCS 29260
|
| Hospital Charge Code |
729260
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$67.20 |
| Max. Negotiated Rate |
$96.00 |
| Rate for Payer: Aetna Commercial |
$91.20
|
| Rate for Payer: Aetna Medicare |
$86.40
|
| Rate for Payer: BCBS MT CHIP |
$86.40
|
| Rate for Payer: BCBS MT Closed Plan Network |
$91.20
|
| Rate for Payer: BCBS MT HealthLink |
$86.40
|
| Rate for Payer: BCBS MT Medicare |
$86.40
|
| Rate for Payer: BCBS MT POS |
$91.20
|
| Rate for Payer: BCBS MT Traditional |
$96.00
|
| Rate for Payer: Cash Price |
$86.40
|
| Rate for Payer: Cigna Commercial |
$91.20
|
| Rate for Payer: Cigna Medicare |
$86.40
|
| Rate for Payer: Medicaid All Medicaid |
$88.32
|
| Rate for Payer: Medicare All Medicare |
$67.20
|
| Rate for Payer: Monida Allegiance |
$91.20
|
| Rate for Payer: Monida First Choice Health |
$93.12
|
| Rate for Payer: Monida Montana Health Co-op |
$91.20
|
| Rate for Payer: Monida PacificSource |
$91.20
|
|
|
PRO FEE ER TX OF TOE FRACTURE
|
Professional
|
Both
|
$32.00
|
|
|
Service Code
|
HCPCS 28515
|
| Hospital Charge Code |
728515
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$22.40 |
| Max. Negotiated Rate |
$32.00 |
| Rate for Payer: Aetna Commercial |
$30.40
|
| Rate for Payer: Aetna Medicare |
$28.80
|
| Rate for Payer: BCBS MT CHIP |
$28.80
|
| Rate for Payer: BCBS MT Closed Plan Network |
$30.40
|
| Rate for Payer: BCBS MT HealthLink |
$28.80
|
| Rate for Payer: BCBS MT Medicare |
$28.80
|
| Rate for Payer: BCBS MT POS |
$30.40
|
| Rate for Payer: BCBS MT Traditional |
$32.00
|
| Rate for Payer: Cash Price |
$28.80
|
| Rate for Payer: Cigna Commercial |
$30.40
|
| Rate for Payer: Cigna Medicare |
$28.80
|
| Rate for Payer: Medicaid All Medicaid |
$29.44
|
| Rate for Payer: Medicare All Medicare |
$22.40
|
| Rate for Payer: Monida Allegiance |
$30.40
|
| Rate for Payer: Monida First Choice Health |
$31.04
|
| Rate for Payer: Monida Montana Health Co-op |
$30.40
|
| Rate for Payer: Monida PacificSource |
$30.40
|
|
|
PRO FEE EXC MALIGNANT LESION INC MARGINS
|
Professional
|
Both
|
$309.00
|
|
|
Service Code
|
HCPCS 11602 AQ
|
| Hospital Charge Code |
711602
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$216.30 |
| Max. Negotiated Rate |
$299.73 |
| Rate for Payer: Aetna Commercial |
$293.55
|
| Rate for Payer: Aetna Medicare |
$278.10
|
| Rate for Payer: Cash Price |
$278.10
|
| Rate for Payer: Medicaid All Medicaid |
$284.28
|
| Rate for Payer: Medicare All Medicare |
$216.30
|
| Rate for Payer: Monida Allegiance |
$293.55
|
| Rate for Payer: Monida First Choice Health |
$299.73
|
| Rate for Payer: Monida Montana Health Co-op |
$293.55
|
| Rate for Payer: Monida PacificSource |
$293.55
|
|
