|
PROFEE FETAL BIOPHYS PROFIL W/O NST
|
Professional
|
Both
|
$141.00
|
|
|
Service Code
|
HCPCS 76819 26
|
| Hospital Charge Code |
50002400
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$98.70 |
| Max. Negotiated Rate |
$136.77 |
| Rate for Payer: Aetna Commercial |
$133.95
|
| Rate for Payer: Aetna Medicare |
$126.90
|
| Rate for Payer: Cash Price |
$126.90
|
| Rate for Payer: Medicaid All Medicaid |
$129.72
|
| Rate for Payer: Medicare All Medicare |
$98.70
|
| Rate for Payer: Monida Allegiance |
$133.95
|
| Rate for Payer: Monida First Choice Health |
$136.77
|
| Rate for Payer: Monida Montana Health Co-op |
$133.95
|
| Rate for Payer: Monida PacificSource |
$133.95
|
|
|
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
|
|
|
PROFEE FXR FULL SPINE W SKULL 2 OR 3 VIE
|
Professional
|
Both
|
$44.00
|
|
|
Service Code
|
HCPCS 72082 26
|
| Hospital Charge Code |
50002255
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$30.80 |
| Max. Negotiated Rate |
$42.68 |
| Rate for Payer: Aetna Commercial |
$41.80
|
| Rate for Payer: Aetna Medicare |
$39.60
|
| Rate for Payer: Cash Price |
$39.60
|
| Rate for Payer: Medicaid All Medicaid |
$40.48
|
| Rate for Payer: Medicare All Medicare |
$30.80
|
| Rate for Payer: Monida Allegiance |
$41.80
|
| Rate for Payer: Monida First Choice Health |
$42.68
|
| Rate for Payer: Monida Montana Health Co-op |
$41.80
|
| Rate for Payer: Monida PacificSource |
$41.80
|
|
|
PRO FEE I&D ABCESS/CYST SIMPLE
|
Professional
|
Both
|
$207.00
|
|
|
Service Code
|
HCPCS 10060
|
| Hospital Charge Code |
710060
|
|
Hospital Revenue Code
|
969
|
| Min. Negotiated Rate |
$144.90 |
| Max. Negotiated Rate |
$200.79 |
| Rate for Payer: Aetna Commercial |
$196.65
|
| Rate for Payer: Aetna Medicare |
$186.30
|
| Rate for Payer: Cash Price |
$186.30
|
| Rate for Payer: Medicaid All Medicaid |
$190.44
|
| Rate for Payer: Medicare All Medicare |
$144.90
|
| Rate for Payer: Monida Allegiance |
$196.65
|
| Rate for Payer: Monida First Choice Health |
$200.79
|
| Rate for Payer: Monida Montana Health Co-op |
$196.65
|
| Rate for Payer: Monida PacificSource |
$196.65
|
|
|
PRO FEE INC&REMOVAL FOREIGN BODY-SIMPLE
|
Professional
|
Both
|
$204.00
|
|
|
Service Code
|
HCPCS 10120
|
| Hospital Charge Code |
710120
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$142.80 |
| Max. Negotiated Rate |
$204.00 |
| Rate for Payer: Aetna Commercial |
$193.80
|
| Rate for Payer: Aetna Medicare |
$183.60
|
| Rate for Payer: BCBS MT CHIP |
$183.60
|
| Rate for Payer: BCBS MT Closed Plan Network |
$193.80
|
| Rate for Payer: BCBS MT HealthLink |
$183.60
|
| Rate for Payer: BCBS MT Medicare |
$183.60
|
| Rate for Payer: BCBS MT POS |
$193.80
|
| Rate for Payer: BCBS MT Traditional |
$204.00
|
| Rate for Payer: Cash Price |
$183.60
|
| Rate for Payer: Cigna Commercial |
$193.80
|
| Rate for Payer: Cigna Medicare |
$183.60
|
| Rate for Payer: Medicaid All Medicaid |
$187.68
|
| Rate for Payer: Medicare All Medicare |
$142.80
|
| Rate for Payer: Monida Allegiance |
$193.80
|
| Rate for Payer: Monida First Choice Health |
$197.88
|
| Rate for Payer: Monida Montana Health Co-op |
$193.80
|
| Rate for Payer: Monida PacificSource |
$193.80
|
|
|
PROFEE INJ ASPIR JOINT INJ INTERM 20605
|
Professional
|
Both
|
$189.00
|
|
|
Service Code
|
HCPCS 20605
|
| Hospital Charge Code |
7620605
|
|
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 INJECTION, THERAPEUTIC CARPAL TN
|
Professional
|
Both
|
$294.00
|
|
|
Service Code
|
HCPCS 20526
|
| Hospital Charge Code |
720526
|
|
Hospital Revenue Code
|
964
|
| 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 INJ FACET JNT C/T 2L W/IMA 64491
|
Professional
|
Both
|
$305.00
|
|
|
Service Code
|
HCPCS 64491
|
| Hospital Charge Code |
764491
|
|
Hospital Revenue Code
|
964
|
| Min. Negotiated Rate |
$213.50 |
| Max. Negotiated Rate |
$305.00 |
| Rate for Payer: Aetna Commercial |
$289.75
|
| Rate for Payer: Aetna Medicare |
$274.50
|
| Rate for Payer: BCBS MT CHIP |
$274.50
|
| Rate for Payer: BCBS MT Closed Plan Network |
$289.75
|
| Rate for Payer: BCBS MT HealthLink |
$274.50
|
| Rate for Payer: BCBS MT Medicare |
$274.50
|
| Rate for Payer: BCBS MT POS |
$289.75
|
| Rate for Payer: BCBS MT Traditional |
$305.00
|
| Rate for Payer: Cash Price |
$274.50
|
| Rate for Payer: Cigna Commercial |
$289.75
|
| Rate for Payer: Cigna Medicare |
$274.50
|
| Rate for Payer: Medicaid All Medicaid |
$280.60
|
| Rate for Payer: Medicare All Medicare |
$213.50
|
| Rate for Payer: Monida Allegiance |
$289.75
|
| Rate for Payer: Monida First Choice Health |
$295.85
|
| Rate for Payer: Monida Montana Health Co-op |
$289.75
|
| Rate for Payer: Monida PacificSource |
$289.75
|
|
|
PRO FEE INTERCOSTAL NV BLK EA ADD 64421
|
Professional
|
Both
|
$125.00
|
|
|
Service Code
|
HCPCS 64421
|
| Hospital Charge Code |
764421
|
|
Hospital Revenue Code
|
964
|
| Min. Negotiated Rate |
$87.50 |
| Max. Negotiated Rate |
$125.00 |
| Rate for Payer: Aetna Commercial |
$118.75
|
| Rate for Payer: Aetna Medicare |
$112.50
|
| Rate for Payer: BCBS MT CHIP |
$112.50
|
| Rate for Payer: BCBS MT Closed Plan Network |
$118.75
|
| Rate for Payer: BCBS MT HealthLink |
$112.50
|
| Rate for Payer: BCBS MT Medicare |
$112.50
|
| Rate for Payer: BCBS MT POS |
$118.75
|
| Rate for Payer: BCBS MT Traditional |
$125.00
|
| Rate for Payer: Cash Price |
$112.50
|
| Rate for Payer: Cigna Commercial |
$118.75
|
| Rate for Payer: Cigna Medicare |
$112.50
|
| Rate for Payer: Medicaid All Medicaid |
$115.00
|
| Rate for Payer: Medicare All Medicare |
$87.50
|
| Rate for Payer: Monida Allegiance |
$118.75
|
| Rate for Payer: Monida First Choice Health |
$121.25
|
| Rate for Payer: Monida Montana Health Co-op |
$118.75
|
| Rate for Payer: Monida PacificSource |
$118.75
|
|
|
PRO FEE INTERMED JOINT INJ W/O US 20605
|
Professional
|
Both
|
$189.00
|
|
|
Service Code
|
HCPCS 20605
|
| Hospital Charge Code |
720605
|
|
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 INT/INJ GENICULAR NERVE 64454
|
Professional
|
Both
|
$424.00
|
|
|
Service Code
|
HCPCS 64454
|
| Hospital Charge Code |
764454
|
|
Hospital Revenue Code
|
964
|
| Min. Negotiated Rate |
$296.80 |
| Max. Negotiated Rate |
$424.00 |
| Rate for Payer: Aetna Commercial |
$402.80
|
| Rate for Payer: Aetna Medicare |
$381.60
|
| Rate for Payer: BCBS MT CHIP |
$381.60
|
| Rate for Payer: BCBS MT Closed Plan Network |
$402.80
|
| Rate for Payer: BCBS MT HealthLink |
$381.60
|
| Rate for Payer: BCBS MT Medicare |
$381.60
|
| Rate for Payer: BCBS MT POS |
$402.80
|
| Rate for Payer: BCBS MT Traditional |
$424.00
|
| Rate for Payer: Cash Price |
$381.60
|
| Rate for Payer: Cigna Commercial |
$402.80
|
| Rate for Payer: Cigna Medicare |
$381.60
|
| Rate for Payer: Medicaid All Medicaid |
$390.08
|
| Rate for Payer: Medicare All Medicare |
$296.80
|
| Rate for Payer: Monida Allegiance |
$402.80
|
| Rate for Payer: Monida First Choice Health |
$411.28
|
| Rate for Payer: Monida Montana Health Co-op |
$402.80
|
| Rate for Payer: Monida PacificSource |
$402.80
|
|
|
PRO FEE INTRCOST NRVE BLOCK SINGLE 64420
|
Professional
|
Both
|
$302.00
|
|
|
Service Code
|
HCPCS 64420
|
| Hospital Charge Code |
764420
|
|
Hospital Revenue Code
|
964
|
| Min. Negotiated Rate |
$211.40 |
| Max. Negotiated Rate |
$302.00 |
| Rate for Payer: Aetna Commercial |
$286.90
|
| Rate for Payer: Aetna Medicare |
$271.80
|
| Rate for Payer: BCBS MT CHIP |
$271.80
|
| Rate for Payer: BCBS MT Closed Plan Network |
$286.90
|
| Rate for Payer: BCBS MT HealthLink |
$271.80
|
| Rate for Payer: BCBS MT Medicare |
$271.80
|
| Rate for Payer: BCBS MT POS |
$286.90
|
| Rate for Payer: BCBS MT Traditional |
$302.00
|
| Rate for Payer: Cash Price |
$271.80
|
| Rate for Payer: Cigna Commercial |
$286.90
|
| Rate for Payer: Cigna Medicare |
$271.80
|
| Rate for Payer: Medicaid All Medicaid |
$277.84
|
| Rate for Payer: Medicare All Medicare |
$211.40
|
| Rate for Payer: Monida Allegiance |
$286.90
|
| Rate for Payer: Monida First Choice Health |
$292.94
|
| Rate for Payer: Monida Montana Health Co-op |
$286.90
|
| Rate for Payer: Monida PacificSource |
$286.90
|
|
|
PRO FEE LAC REPAIR CMPL FC/HNADD ON =>5C
|
Professional
|
Both
|
$236.00
|
|
|
Service Code
|
HCPCS 13133 AQ
|
| Hospital Charge Code |
713133
|
|
Hospital Revenue Code
|
981
|
| 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 LAC REPAIR COMPLEX 2.6-7.5CM
|
Professional
|
Both
|
$574.00
|
|
|
Service Code
|
HCPCS 13132 AQ
|
| Hospital Charge Code |
713132
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$401.80 |
| Max. Negotiated Rate |
$574.00 |
| Rate for Payer: Aetna Commercial |
$545.30
|
| Rate for Payer: Aetna Medicare |
$516.60
|
| Rate for Payer: BCBS MT CHIP |
$516.60
|
| Rate for Payer: BCBS MT Closed Plan Network |
$545.30
|
| Rate for Payer: BCBS MT HealthLink |
$516.60
|
| Rate for Payer: BCBS MT Medicare |
$516.60
|
| Rate for Payer: BCBS MT POS |
$545.30
|
| Rate for Payer: BCBS MT Traditional |
$574.00
|
| Rate for Payer: Cash Price |
$516.60
|
| Rate for Payer: Cigna Commercial |
$545.30
|
| Rate for Payer: Cigna Medicare |
$516.60
|
| Rate for Payer: Medicaid All Medicaid |
$528.08
|
| Rate for Payer: Medicare All Medicare |
$401.80
|
| Rate for Payer: Monida Allegiance |
$545.30
|
| Rate for Payer: Monida First Choice Health |
$556.78
|
| Rate for Payer: Monida Montana Health Co-op |
$545.30
|
| Rate for Payer: Monida PacificSource |
$545.30
|
|
|
PRO FEE LAC REPAIR COMPLEX 2.6-7.5CM
|
Professional
|
Both
|
$491.00
|
|
|
Service Code
|
HCPCS 13121 AQ
|
| Hospital Charge Code |
713121
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$343.70 |
| Max. Negotiated Rate |
$491.00 |
| Rate for Payer: Aetna Commercial |
$466.45
|
| Rate for Payer: Aetna Medicare |
$441.90
|
| Rate for Payer: BCBS MT CHIP |
$441.90
|
| Rate for Payer: BCBS MT Closed Plan Network |
$466.45
|
| Rate for Payer: BCBS MT HealthLink |
$441.90
|
| Rate for Payer: BCBS MT Medicare |
$441.90
|
| Rate for Payer: BCBS MT POS |
$466.45
|
| Rate for Payer: BCBS MT Traditional |
$491.00
|
| Rate for Payer: Cash Price |
$441.90
|
| Rate for Payer: Cigna Commercial |
$466.45
|
| Rate for Payer: Cigna Medicare |
$441.90
|
| Rate for Payer: Medicaid All Medicaid |
$451.72
|
| Rate for Payer: Medicare All Medicare |
$343.70
|
| Rate for Payer: Monida Allegiance |
$466.45
|
| Rate for Payer: Monida First Choice Health |
$476.27
|
| Rate for Payer: Monida Montana Health Co-op |
$466.45
|
| Rate for Payer: Monida PacificSource |
$466.45
|
|
|
PRO FEE LAC REPAIR SIMPLE=<2.5CM
|
Professional
|
Both
|
$84.00
|
|
|
Service Code
|
HCPCS 12001 AQ
|
| Hospital Charge Code |
712001
|
|
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 2.6-7.5CM
|
Professional
|
Both
|
$111.00
|
|
|
Service Code
|
HCPCS 12002 AQ
|
| Hospital Charge Code |
712002
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$77.70 |
| Max. Negotiated Rate |
$111.00 |
| Rate for Payer: Aetna Commercial |
$105.45
|
| Rate for Payer: Aetna Medicare |
$99.90
|
| Rate for Payer: BCBS MT CHIP |
$99.90
|
| Rate for Payer: BCBS MT Closed Plan Network |
$105.45
|
| Rate for Payer: BCBS MT HealthLink |
$99.90
|
| Rate for Payer: BCBS MT Medicare |
$99.90
|
| Rate for Payer: BCBS MT POS |
$105.45
|
| Rate for Payer: BCBS MT Traditional |
$111.00
|
| Rate for Payer: Cash Price |
$99.90
|
| Rate for Payer: Cigna Commercial |
$105.45
|
| Rate for Payer: Cigna Medicare |
$99.90
|
| Rate for Payer: Medicaid All Medicaid |
$102.12
|
| Rate for Payer: Medicare All Medicare |
$77.70
|
| Rate for Payer: Monida Allegiance |
$105.45
|
| Rate for Payer: Monida First Choice Health |
$107.67
|
| Rate for Payer: Monida Montana Health Co-op |
$105.45
|
| Rate for Payer: Monida PacificSource |
$105.45
|
|
|
PRO FEE LAC REPAIR SIMPLE 7.6-12.5CM
|
Professional
|
Both
|
$138.00
|
|
|
Service Code
|
HCPCS 12004 AQ
|
| Hospital Charge Code |
712004
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$96.60 |
| Max. Negotiated Rate |
$138.00 |
| Rate for Payer: Aetna Commercial |
$131.10
|
| Rate for Payer: Aetna Medicare |
$124.20
|
| Rate for Payer: BCBS MT CHIP |
$124.20
|
| Rate for Payer: BCBS MT Closed Plan Network |
$131.10
|
| Rate for Payer: BCBS MT HealthLink |
$124.20
|
| Rate for Payer: BCBS MT Medicare |
$124.20
|
| Rate for Payer: BCBS MT POS |
$131.10
|
| Rate for Payer: BCBS MT Traditional |
$138.00
|
| Rate for Payer: Cash Price |
$124.20
|
| Rate for Payer: Cigna Commercial |
$131.10
|
| Rate for Payer: Cigna Medicare |
$124.20
|
| Rate for Payer: Medicaid All Medicaid |
$126.96
|
| Rate for Payer: Medicare All Medicare |
$96.60
|
| Rate for Payer: Monida Allegiance |
$131.10
|
| Rate for Payer: Monida First Choice Health |
$133.86
|
| Rate for Payer: Monida Montana Health Co-op |
$131.10
|
| Rate for Payer: Monida PacificSource |
$131.10
|
|
|
PRO FEE MAJOR JOINT INJ W/O US 20610
|
Professional
|
Both
|
$234.00
|
|
|
Service Code
|
HCPCS 20610
|
| Hospital Charge Code |
720610
|
|
Hospital Revenue Code
|
964
|
| Min. Negotiated Rate |
$163.80 |
| Max. Negotiated Rate |
$234.00 |
| Rate for Payer: Aetna Commercial |
$222.30
|
| Rate for Payer: Aetna Medicare |
$210.60
|
| Rate for Payer: BCBS MT CHIP |
$210.60
|
| Rate for Payer: BCBS MT Closed Plan Network |
$222.30
|
| Rate for Payer: BCBS MT HealthLink |
$210.60
|
| Rate for Payer: BCBS MT Medicare |
$210.60
|
| Rate for Payer: BCBS MT POS |
$222.30
|
| Rate for Payer: BCBS MT Traditional |
$234.00
|
| Rate for Payer: Cash Price |
$210.60
|
| Rate for Payer: Cigna Commercial |
$222.30
|
| Rate for Payer: Cigna Medicare |
$210.60
|
| Rate for Payer: Medicaid All Medicaid |
$215.28
|
| Rate for Payer: Medicare All Medicare |
$163.80
|
| Rate for Payer: Monida Allegiance |
$222.30
|
| Rate for Payer: Monida First Choice Health |
$226.98
|
| Rate for Payer: Monida Montana Health Co-op |
$222.30
|
| Rate for Payer: Monida PacificSource |
$222.30
|
|
|
PROFEE MRA ABDOMEN W WO CONTRAST
|
Professional
|
Both
|
$252.00
|
|
|
Service Code
|
HCPCS 74185 26
|
| Hospital Charge Code |
50002211
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$176.40 |
| Max. Negotiated Rate |
$244.44 |
| Rate for Payer: Aetna Commercial |
$239.40
|
| Rate for Payer: Aetna Medicare |
$226.80
|
| Rate for Payer: Cash Price |
$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
|
|
|
PROFEE MR ABDOMEN W CONTRAST
|
Professional
|
Both
|
$243.00
|
|
|
Service Code
|
HCPCS 74182 26
|
| Hospital Charge Code |
50002090
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$170.10 |
| Max. Negotiated Rate |
$235.71 |
| Rate for Payer: Aetna Commercial |
$230.85
|
| Rate for Payer: Aetna Medicare |
$218.70
|
| Rate for Payer: Cash Price |
$218.70
|
| Rate for Payer: Medicaid All Medicaid |
$223.56
|
| Rate for Payer: Medicare All Medicare |
$170.10
|
| Rate for Payer: Monida Allegiance |
$230.85
|
| Rate for Payer: Monida First Choice Health |
$235.71
|
| Rate for Payer: Monida Montana Health Co-op |
$230.85
|
| Rate for Payer: Monida PacificSource |
$230.85
|
|
|
PROFEE MR ABDOMEN WO CONTRAST
|
Professional
|
Both
|
$205.00
|
|
|
Service Code
|
HCPCS 74181 26
|
| Hospital Charge Code |
50002092
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$143.50 |
| Max. Negotiated Rate |
$198.85 |
| Rate for Payer: Aetna Commercial |
$194.75
|
| Rate for Payer: Aetna Medicare |
$184.50
|
| Rate for Payer: Cash Price |
$184.50
|
| Rate for Payer: Medicaid All Medicaid |
$188.60
|
| Rate for Payer: Medicare All Medicare |
$143.50
|
| Rate for Payer: Monida Allegiance |
$194.75
|
| Rate for Payer: Monida First Choice Health |
$198.85
|
| Rate for Payer: Monida Montana Health Co-op |
$194.75
|
| Rate for Payer: Monida PacificSource |
$194.75
|
|
|
PROFEE MR ABDOMEN W WO CONTRAST
|
Professional
|
Both
|
$312.00
|
|
|
Service Code
|
HCPCS 74183 26
|
| Hospital Charge Code |
50002091
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$218.40 |
| Max. Negotiated Rate |
$302.64 |
| Rate for Payer: Aetna Commercial |
$296.40
|
| Rate for Payer: Aetna Medicare |
$280.80
|
| Rate for Payer: Cash Price |
$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
|
|
|
PROFEE MRA CHEST W WO CONTRAST
|
Professional
|
Both
|
$252.00
|
|
|
Service Code
|
HCPCS 71555 26
|
| Hospital Charge Code |
50002212
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$176.40 |
| Max. Negotiated Rate |
$244.44 |
| Rate for Payer: Aetna Commercial |
$239.40
|
| Rate for Payer: Aetna Medicare |
$226.80
|
| Rate for Payer: Cash Price |
$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
|
|
|
PROFEE MRA HEAD W CONTRAST
|
Professional
|
Both
|
$168.00
|
|
|
Service Code
|
HCPCS 70545 26
|
| Hospital Charge Code |
50002213
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$117.60 |
| Max. Negotiated Rate |
$162.96 |
| Rate for Payer: Aetna Commercial |
$159.60
|
| Rate for Payer: Aetna Medicare |
$151.20
|
| Rate for Payer: Cash Price |
$151.20
|
| Rate for Payer: Medicaid All Medicaid |
$154.56
|
| Rate for Payer: Medicare All Medicare |
$117.60
|
| Rate for Payer: Monida Allegiance |
$159.60
|
| Rate for Payer: Monida First Choice Health |
$162.96
|
| Rate for Payer: Monida Montana Health Co-op |
$159.60
|
| Rate for Payer: Monida PacificSource |
$159.60
|
|
