|
PRO FEE OP IJ DESTR, PLANTAR NERV 64632
|
Professional
|
Both
|
$351.00
|
|
|
Service Code
|
HCPCS 64632
|
| Hospital Charge Code |
764632
|
|
Hospital Revenue Code
|
964
|
| Min. Negotiated Rate |
$245.70 |
| Max. Negotiated Rate |
$351.00 |
| Rate for Payer: Aetna Commercial |
$333.45
|
| Rate for Payer: Aetna Medicare |
$315.90
|
| Rate for Payer: BCBS MT CHIP |
$315.90
|
| Rate for Payer: BCBS MT Closed Plan Network |
$333.45
|
| Rate for Payer: BCBS MT HealthLink |
$315.90
|
| Rate for Payer: BCBS MT Medicare |
$315.90
|
| Rate for Payer: BCBS MT POS |
$333.45
|
| Rate for Payer: BCBS MT Traditional |
$351.00
|
| Rate for Payer: Cash Price |
$315.90
|
| Rate for Payer: Cigna Commercial |
$333.45
|
| Rate for Payer: Cigna Medicare |
$315.90
|
| Rate for Payer: Medicaid All Medicaid |
$322.92
|
| Rate for Payer: Medicare All Medicare |
$245.70
|
| Rate for Payer: Monida Allegiance |
$333.45
|
| Rate for Payer: Monida First Choice Health |
$340.47
|
| Rate for Payer: Monida Montana Health Co-op |
$333.45
|
| Rate for Payer: Monida PacificSource |
$333.45
|
|
|
PRO FEE OP IJ DESTR, PUDENDAL NERV 64630
|
Professional
|
Both
|
$1,002.00
|
|
|
Service Code
|
HCPCS 64630
|
| Hospital Charge Code |
764630
|
|
Hospital Revenue Code
|
964
|
| Min. Negotiated Rate |
$701.40 |
| Max. Negotiated Rate |
$1,002.00 |
| Rate for Payer: Aetna Commercial |
$951.90
|
| Rate for Payer: Aetna Medicare |
$901.80
|
| Rate for Payer: BCBS MT CHIP |
$901.80
|
| Rate for Payer: BCBS MT Closed Plan Network |
$951.90
|
| Rate for Payer: BCBS MT HealthLink |
$901.80
|
| Rate for Payer: BCBS MT Medicare |
$901.80
|
| Rate for Payer: BCBS MT POS |
$951.90
|
| Rate for Payer: BCBS MT Traditional |
$1,002.00
|
| Rate for Payer: Cash Price |
$901.80
|
| Rate for Payer: Cigna Commercial |
$951.90
|
| Rate for Payer: Cigna Medicare |
$901.80
|
| Rate for Payer: Medicaid All Medicaid |
$921.84
|
| Rate for Payer: Medicare All Medicare |
$701.40
|
| Rate for Payer: Monida Allegiance |
$951.90
|
| Rate for Payer: Monida First Choice Health |
$971.94
|
| Rate for Payer: Monida Montana Health Co-op |
$951.90
|
| Rate for Payer: Monida PacificSource |
$951.90
|
|
|
PRO FEE OP IJ DST. F NER MIGRN TRT 64615
|
Professional
|
Both
|
$638.00
|
|
|
Service Code
|
HCPCS 64615
|
| Hospital Charge Code |
764615
|
|
Hospital Revenue Code
|
964
|
| Min. Negotiated Rate |
$446.60 |
| Max. Negotiated Rate |
$638.00 |
| Rate for Payer: Aetna Commercial |
$606.10
|
| Rate for Payer: Aetna Medicare |
$574.20
|
| Rate for Payer: BCBS MT CHIP |
$574.20
|
| Rate for Payer: BCBS MT Closed Plan Network |
$606.10
|
| Rate for Payer: BCBS MT HealthLink |
$574.20
|
| Rate for Payer: BCBS MT Medicare |
$574.20
|
| Rate for Payer: BCBS MT POS |
$606.10
|
| Rate for Payer: BCBS MT Traditional |
$638.00
|
| Rate for Payer: Cash Price |
$574.20
|
| Rate for Payer: Cigna Commercial |
$606.10
|
| Rate for Payer: Cigna Medicare |
$574.20
|
| Rate for Payer: Medicaid All Medicaid |
$586.96
|
| Rate for Payer: Medicare All Medicare |
$446.60
|
| Rate for Payer: Monida Allegiance |
$606.10
|
| Rate for Payer: Monida First Choice Health |
$618.86
|
| Rate for Payer: Monida Montana Health Co-op |
$606.10
|
| Rate for Payer: Monida PacificSource |
$606.10
|
|
|
PRO FEE OP IJ GREATER OCCIP NV BLK 64405
|
Professional
|
Both
|
$273.00
|
|
|
Service Code
|
HCPCS 64405
|
| Hospital Charge Code |
764405
|
|
Hospital Revenue Code
|
964
|
| Min. Negotiated Rate |
$191.10 |
| Max. Negotiated Rate |
$273.00 |
| Rate for Payer: Aetna Commercial |
$259.35
|
| Rate for Payer: Aetna Medicare |
$245.70
|
| Rate for Payer: BCBS MT CHIP |
$245.70
|
| Rate for Payer: BCBS MT Closed Plan Network |
$259.35
|
| Rate for Payer: BCBS MT HealthLink |
$245.70
|
| Rate for Payer: BCBS MT Medicare |
$245.70
|
| Rate for Payer: BCBS MT POS |
$259.35
|
| Rate for Payer: BCBS MT Traditional |
$273.00
|
| Rate for Payer: Cash Price |
$245.70
|
| Rate for Payer: Cigna Commercial |
$259.35
|
| Rate for Payer: Cigna Medicare |
$245.70
|
| Rate for Payer: Medicaid All Medicaid |
$251.16
|
| Rate for Payer: Medicare All Medicare |
$191.10
|
| Rate for Payer: Monida Allegiance |
$259.35
|
| Rate for Payer: Monida First Choice Health |
$264.81
|
| Rate for Payer: Monida Montana Health Co-op |
$259.35
|
| Rate for Payer: Monida PacificSource |
$259.35
|
|
|
PRO FEE OP IJ RFA C/T 1ST JOINT 64633
|
Professional
|
Both
|
$992.00
|
|
|
Service Code
|
HCPCS 64633
|
| Hospital Charge Code |
764633
|
|
Hospital Revenue Code
|
964
|
| Min. Negotiated Rate |
$694.40 |
| Max. Negotiated Rate |
$992.00 |
| Rate for Payer: Aetna Commercial |
$942.40
|
| Rate for Payer: Aetna Medicare |
$892.80
|
| Rate for Payer: BCBS MT CHIP |
$892.80
|
| Rate for Payer: BCBS MT Closed Plan Network |
$942.40
|
| Rate for Payer: BCBS MT HealthLink |
$892.80
|
| Rate for Payer: BCBS MT Medicare |
$892.80
|
| Rate for Payer: BCBS MT POS |
$942.40
|
| Rate for Payer: BCBS MT Traditional |
$992.00
|
| Rate for Payer: Cash Price |
$892.80
|
| Rate for Payer: Cigna Commercial |
$942.40
|
| Rate for Payer: Cigna Medicare |
$892.80
|
| Rate for Payer: Medicaid All Medicaid |
$912.64
|
| Rate for Payer: Medicare All Medicare |
$694.40
|
| Rate for Payer: Monida Allegiance |
$942.40
|
| Rate for Payer: Monida First Choice Health |
$962.24
|
| Rate for Payer: Monida Montana Health Co-op |
$942.40
|
| Rate for Payer: Monida PacificSource |
$942.40
|
|
|
PRO FEE OP IJ RFA C/T EA AD ON JT 64634
|
Professional
|
Both
|
$343.00
|
|
|
Service Code
|
HCPCS 64634
|
| Hospital Charge Code |
764634
|
|
Hospital Revenue Code
|
964
|
| Min. Negotiated Rate |
$240.10 |
| Max. Negotiated Rate |
$343.00 |
| Rate for Payer: Aetna Commercial |
$325.85
|
| Rate for Payer: Aetna Medicare |
$308.70
|
| Rate for Payer: BCBS MT CHIP |
$308.70
|
| Rate for Payer: BCBS MT Closed Plan Network |
$325.85
|
| Rate for Payer: BCBS MT HealthLink |
$308.70
|
| Rate for Payer: BCBS MT Medicare |
$308.70
|
| Rate for Payer: BCBS MT POS |
$325.85
|
| Rate for Payer: BCBS MT Traditional |
$343.00
|
| Rate for Payer: Cash Price |
$308.70
|
| Rate for Payer: Cigna Commercial |
$325.85
|
| Rate for Payer: Cigna Medicare |
$308.70
|
| Rate for Payer: Medicaid All Medicaid |
$315.56
|
| Rate for Payer: Medicare All Medicare |
$240.10
|
| Rate for Payer: Monida Allegiance |
$325.85
|
| Rate for Payer: Monida First Choice Health |
$332.71
|
| Rate for Payer: Monida Montana Health Co-op |
$325.85
|
| Rate for Payer: Monida PacificSource |
$325.85
|
|
|
PRO FEE OP IJ RFA PERPH NV/SUPSCAP 64640
|
Professional
|
Both
|
$623.00
|
|
|
Service Code
|
HCPCS 64640
|
| Hospital Charge Code |
764640
|
|
Hospital Revenue Code
|
964
|
| Min. Negotiated Rate |
$436.10 |
| Max. Negotiated Rate |
$623.00 |
| Rate for Payer: Aetna Commercial |
$591.85
|
| Rate for Payer: Aetna Medicare |
$560.70
|
| Rate for Payer: BCBS MT CHIP |
$560.70
|
| Rate for Payer: BCBS MT Closed Plan Network |
$591.85
|
| Rate for Payer: BCBS MT HealthLink |
$560.70
|
| Rate for Payer: BCBS MT Medicare |
$560.70
|
| Rate for Payer: BCBS MT POS |
$591.85
|
| Rate for Payer: BCBS MT Traditional |
$623.00
|
| Rate for Payer: Cash Price |
$560.70
|
| Rate for Payer: Cigna Commercial |
$591.85
|
| Rate for Payer: Cigna Medicare |
$560.70
|
| Rate for Payer: Medicaid All Medicaid |
$573.16
|
| Rate for Payer: Medicare All Medicare |
$436.10
|
| Rate for Payer: Monida Allegiance |
$591.85
|
| Rate for Payer: Monida First Choice Health |
$604.31
|
| Rate for Payer: Monida Montana Health Co-op |
$591.85
|
| Rate for Payer: Monida PacificSource |
$591.85
|
|
|
PRO FEE OP IJ TRANSFOR L/S ADD 64484
|
Professional
|
Both
|
$259.00
|
|
|
Service Code
|
HCPCS 64484
|
| Hospital Charge Code |
764484
|
|
Hospital Revenue Code
|
964
|
| Min. Negotiated Rate |
$181.30 |
| Max. Negotiated Rate |
$259.00 |
| Rate for Payer: Aetna Commercial |
$246.05
|
| Rate for Payer: Aetna Medicare |
$233.10
|
| Rate for Payer: BCBS MT CHIP |
$233.10
|
| Rate for Payer: BCBS MT Closed Plan Network |
$246.05
|
| Rate for Payer: BCBS MT HealthLink |
$233.10
|
| Rate for Payer: BCBS MT Medicare |
$233.10
|
| Rate for Payer: BCBS MT POS |
$246.05
|
| Rate for Payer: BCBS MT Traditional |
$259.00
|
| Rate for Payer: Cash Price |
$233.10
|
| Rate for Payer: Cigna Commercial |
$246.05
|
| Rate for Payer: Cigna Medicare |
$233.10
|
| Rate for Payer: Medicaid All Medicaid |
$238.28
|
| Rate for Payer: Medicare All Medicare |
$181.30
|
| Rate for Payer: Monida Allegiance |
$246.05
|
| Rate for Payer: Monida First Choice Health |
$251.23
|
| Rate for Payer: Monida Montana Health Co-op |
$246.05
|
| Rate for Payer: Monida PacificSource |
$246.05
|
|
|
PRO FEE OP INJ BRACHIAL PLEX W/IMG 64415
|
Professional
|
Both
|
$356.00
|
|
|
Service Code
|
HCPCS 64415
|
| Hospital Charge Code |
764415
|
|
Hospital Revenue Code
|
964
|
| Min. Negotiated Rate |
$249.20 |
| Max. Negotiated Rate |
$356.00 |
| Rate for Payer: Aetna Commercial |
$338.20
|
| Rate for Payer: Aetna Medicare |
$320.40
|
| Rate for Payer: BCBS MT CHIP |
$320.40
|
| Rate for Payer: BCBS MT Closed Plan Network |
$338.20
|
| Rate for Payer: BCBS MT HealthLink |
$320.40
|
| Rate for Payer: BCBS MT Medicare |
$320.40
|
| Rate for Payer: BCBS MT POS |
$338.20
|
| Rate for Payer: BCBS MT Traditional |
$356.00
|
| Rate for Payer: Cash Price |
$320.40
|
| Rate for Payer: Cigna Commercial |
$338.20
|
| Rate for Payer: Cigna Medicare |
$320.40
|
| Rate for Payer: Medicaid All Medicaid |
$327.52
|
| Rate for Payer: Medicare All Medicare |
$249.20
|
| Rate for Payer: Monida Allegiance |
$338.20
|
| Rate for Payer: Monida First Choice Health |
$345.32
|
| Rate for Payer: Monida Montana Health Co-op |
$338.20
|
| Rate for Payer: Monida PacificSource |
$338.20
|
|
|
PRO FEE OP INJ CELIAC PLEX BLOCK 64530
|
Professional
|
Both
|
$489.00
|
|
|
Service Code
|
HCPCS 64530
|
| Hospital Charge Code |
764530
|
|
Hospital Revenue Code
|
964
|
| Min. Negotiated Rate |
$342.30 |
| Max. Negotiated Rate |
$489.00 |
| Rate for Payer: Aetna Commercial |
$464.55
|
| Rate for Payer: Aetna Medicare |
$440.10
|
| Rate for Payer: BCBS MT CHIP |
$440.10
|
| Rate for Payer: BCBS MT Closed Plan Network |
$464.55
|
| Rate for Payer: BCBS MT HealthLink |
$440.10
|
| Rate for Payer: BCBS MT Medicare |
$440.10
|
| Rate for Payer: BCBS MT POS |
$464.55
|
| Rate for Payer: BCBS MT Traditional |
$489.00
|
| Rate for Payer: Cash Price |
$440.10
|
| Rate for Payer: Cigna Commercial |
$464.55
|
| Rate for Payer: Cigna Medicare |
$440.10
|
| Rate for Payer: Medicaid All Medicaid |
$449.88
|
| Rate for Payer: Medicare All Medicare |
$342.30
|
| Rate for Payer: Monida Allegiance |
$464.55
|
| Rate for Payer: Monida First Choice Health |
$474.33
|
| Rate for Payer: Monida Montana Health Co-op |
$464.55
|
| Rate for Payer: Monida PacificSource |
$464.55
|
|
|
PRO FEE OP INJ DEST OF FACIAL NER 64612
|
Professional
|
Both
|
$623.00
|
|
|
Service Code
|
HCPCS 64612
|
| Hospital Charge Code |
764612
|
|
Hospital Revenue Code
|
964
|
| Min. Negotiated Rate |
$436.10 |
| Max. Negotiated Rate |
$623.00 |
| Rate for Payer: Aetna Commercial |
$591.85
|
| Rate for Payer: Aetna Medicare |
$560.70
|
| Rate for Payer: BCBS MT CHIP |
$560.70
|
| Rate for Payer: BCBS MT Closed Plan Network |
$591.85
|
| Rate for Payer: BCBS MT HealthLink |
$560.70
|
| Rate for Payer: BCBS MT Medicare |
$560.70
|
| Rate for Payer: BCBS MT POS |
$591.85
|
| Rate for Payer: BCBS MT Traditional |
$623.00
|
| Rate for Payer: Cash Price |
$560.70
|
| Rate for Payer: Cigna Commercial |
$591.85
|
| Rate for Payer: Cigna Medicare |
$560.70
|
| Rate for Payer: Medicaid All Medicaid |
$573.16
|
| Rate for Payer: Medicare All Medicare |
$436.10
|
| Rate for Payer: Monida Allegiance |
$591.85
|
| Rate for Payer: Monida First Choice Health |
$604.31
|
| Rate for Payer: Monida Montana Health Co-op |
$591.85
|
| Rate for Payer: Monida PacificSource |
$591.85
|
|
|
PRO FEE OP INJ FACET JNT C/T 1L 64490
|
Professional
|
Both
|
$544.00
|
|
|
Service Code
|
HCPCS 64490
|
| Hospital Charge Code |
764490
|
|
Hospital Revenue Code
|
964
|
| Min. Negotiated Rate |
$380.80 |
| Max. Negotiated Rate |
$544.00 |
| Rate for Payer: Aetna Commercial |
$516.80
|
| Rate for Payer: Aetna Medicare |
$489.60
|
| Rate for Payer: BCBS MT CHIP |
$489.60
|
| Rate for Payer: BCBS MT Closed Plan Network |
$516.80
|
| Rate for Payer: BCBS MT HealthLink |
$489.60
|
| Rate for Payer: BCBS MT Medicare |
$489.60
|
| Rate for Payer: BCBS MT POS |
$516.80
|
| Rate for Payer: BCBS MT Traditional |
$544.00
|
| Rate for Payer: Cash Price |
$489.60
|
| Rate for Payer: Cigna Commercial |
$516.80
|
| Rate for Payer: Cigna Medicare |
$489.60
|
| Rate for Payer: Medicaid All Medicaid |
$500.48
|
| Rate for Payer: Medicare All Medicare |
$380.80
|
| Rate for Payer: Monida Allegiance |
$516.80
|
| Rate for Payer: Monida First Choice Health |
$527.68
|
| Rate for Payer: Monida Montana Health Co-op |
$516.80
|
| Rate for Payer: Monida PacificSource |
$516.80
|
|
|
PRO FEE OP INJ FACET JNT C/T 3RDL 64492
|
Professional
|
Both
|
$307.00
|
|
|
Service Code
|
HCPCS 64492
|
| Hospital Charge Code |
764492
|
|
Hospital Revenue Code
|
964
|
| Min. Negotiated Rate |
$214.90 |
| Max. Negotiated Rate |
$307.00 |
| Rate for Payer: Aetna Commercial |
$291.65
|
| Rate for Payer: Aetna Medicare |
$276.30
|
| Rate for Payer: BCBS MT CHIP |
$276.30
|
| Rate for Payer: BCBS MT Closed Plan Network |
$291.65
|
| Rate for Payer: BCBS MT HealthLink |
$276.30
|
| Rate for Payer: BCBS MT Medicare |
$276.30
|
| Rate for Payer: BCBS MT POS |
$291.65
|
| Rate for Payer: BCBS MT Traditional |
$307.00
|
| Rate for Payer: Cash Price |
$276.30
|
| Rate for Payer: Cigna Commercial |
$291.65
|
| Rate for Payer: Cigna Medicare |
$276.30
|
| Rate for Payer: Medicaid All Medicaid |
$282.44
|
| Rate for Payer: Medicare All Medicare |
$214.90
|
| Rate for Payer: Monida Allegiance |
$291.65
|
| Rate for Payer: Monida First Choice Health |
$297.79
|
| Rate for Payer: Monida Montana Health Co-op |
$291.65
|
| Rate for Payer: Monida PacificSource |
$291.65
|
|
|
PRO FEE OP INJ FACET JNT L/S 1 L64493
|
Professional
|
Both
|
$470.00
|
|
|
Service Code
|
HCPCS 64493
|
| Hospital Charge Code |
764493
|
|
Hospital Revenue Code
|
964
|
| Min. Negotiated Rate |
$329.00 |
| Max. Negotiated Rate |
$470.00 |
| Rate for Payer: Aetna Commercial |
$446.50
|
| Rate for Payer: Aetna Medicare |
$423.00
|
| Rate for Payer: BCBS MT CHIP |
$423.00
|
| Rate for Payer: BCBS MT Closed Plan Network |
$446.50
|
| Rate for Payer: BCBS MT HealthLink |
$423.00
|
| Rate for Payer: BCBS MT Medicare |
$423.00
|
| Rate for Payer: BCBS MT POS |
$446.50
|
| Rate for Payer: BCBS MT Traditional |
$470.00
|
| Rate for Payer: Cash Price |
$423.00
|
| Rate for Payer: Cigna Commercial |
$446.50
|
| Rate for Payer: Cigna Medicare |
$423.00
|
| Rate for Payer: Medicaid All Medicaid |
$432.40
|
| Rate for Payer: Medicare All Medicare |
$329.00
|
| Rate for Payer: Monida Allegiance |
$446.50
|
| Rate for Payer: Monida First Choice Health |
$455.90
|
| Rate for Payer: Monida Montana Health Co-op |
$446.50
|
| Rate for Payer: Monida PacificSource |
$446.50
|
|
|
PRO FEE OP INJ FACET JNT L/S 2 L 64494
|
Professional
|
Both
|
$261.00
|
|
|
Service Code
|
HCPCS 64494
|
| Hospital Charge Code |
764494
|
|
Hospital Revenue Code
|
964
|
| Min. Negotiated Rate |
$182.70 |
| Max. Negotiated Rate |
$261.00 |
| Rate for Payer: Aetna Commercial |
$247.95
|
| Rate for Payer: Aetna Medicare |
$234.90
|
| Rate for Payer: BCBS MT CHIP |
$234.90
|
| Rate for Payer: BCBS MT Closed Plan Network |
$247.95
|
| Rate for Payer: BCBS MT HealthLink |
$234.90
|
| Rate for Payer: BCBS MT Medicare |
$234.90
|
| Rate for Payer: BCBS MT POS |
$247.95
|
| Rate for Payer: BCBS MT Traditional |
$261.00
|
| Rate for Payer: Cash Price |
$234.90
|
| Rate for Payer: Cigna Commercial |
$247.95
|
| Rate for Payer: Cigna Medicare |
$234.90
|
| Rate for Payer: Medicaid All Medicaid |
$240.12
|
| Rate for Payer: Medicare All Medicare |
$182.70
|
| Rate for Payer: Monida Allegiance |
$247.95
|
| Rate for Payer: Monida First Choice Health |
$253.17
|
| Rate for Payer: Monida Montana Health Co-op |
$247.95
|
| Rate for Payer: Monida PacificSource |
$247.95
|
|
|
PRO FEE OP INJ FACET JNT L/S 3L 64495
|
Professional
|
Both
|
$262.00
|
|
|
Service Code
|
HCPCS 64495
|
| Hospital Charge Code |
764495
|
|
Hospital Revenue Code
|
964
|
| 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 OP INJ FEMORAL NERVE BLOCK 64447
|
Professional
|
Both
|
$325.00
|
|
|
Service Code
|
HCPCS 64447
|
| Hospital Charge Code |
764447
|
|
Hospital Revenue Code
|
964
|
| Min. Negotiated Rate |
$227.50 |
| Max. Negotiated Rate |
$325.00 |
| Rate for Payer: Aetna Commercial |
$308.75
|
| Rate for Payer: Aetna Medicare |
$292.50
|
| Rate for Payer: BCBS MT CHIP |
$292.50
|
| Rate for Payer: BCBS MT Closed Plan Network |
$308.75
|
| Rate for Payer: BCBS MT HealthLink |
$292.50
|
| Rate for Payer: BCBS MT Medicare |
$292.50
|
| Rate for Payer: BCBS MT POS |
$308.75
|
| Rate for Payer: BCBS MT Traditional |
$325.00
|
| Rate for Payer: Cash Price |
$292.50
|
| Rate for Payer: Cigna Commercial |
$308.75
|
| Rate for Payer: Cigna Medicare |
$292.50
|
| Rate for Payer: Medicaid All Medicaid |
$299.00
|
| Rate for Payer: Medicare All Medicare |
$227.50
|
| Rate for Payer: Monida Allegiance |
$308.75
|
| Rate for Payer: Monida First Choice Health |
$315.25
|
| Rate for Payer: Monida Montana Health Co-op |
$308.75
|
| Rate for Payer: Monida PacificSource |
$308.75
|
|
|
PRO FEE OP INJ ILIOING/ILIOHYPOG 64425
|
Professional
|
Both
|
$280.00
|
|
|
Service Code
|
HCPCS 64425
|
| Hospital Charge Code |
764425
|
|
Hospital Revenue Code
|
964
|
| Min. Negotiated Rate |
$196.00 |
| Max. Negotiated Rate |
$280.00 |
| Rate for Payer: Aetna Commercial |
$266.00
|
| Rate for Payer: Aetna Medicare |
$252.00
|
| Rate for Payer: BCBS MT CHIP |
$252.00
|
| Rate for Payer: BCBS MT Closed Plan Network |
$266.00
|
| Rate for Payer: BCBS MT HealthLink |
$252.00
|
| Rate for Payer: BCBS MT Medicare |
$252.00
|
| Rate for Payer: BCBS MT POS |
$266.00
|
| Rate for Payer: BCBS MT Traditional |
$280.00
|
| Rate for Payer: Cash Price |
$252.00
|
| Rate for Payer: Cigna Commercial |
$266.00
|
| Rate for Payer: Cigna Medicare |
$252.00
|
| Rate for Payer: Medicaid All Medicaid |
$257.60
|
| Rate for Payer: Medicare All Medicare |
$196.00
|
| Rate for Payer: Monida Allegiance |
$266.00
|
| Rate for Payer: Monida First Choice Health |
$271.60
|
| Rate for Payer: Monida Montana Health Co-op |
$266.00
|
| Rate for Payer: Monida PacificSource |
$266.00
|
|
|
PROFEE OP INJ INTERLAM C-T 762321
|
Professional
|
Both
|
$551.00
|
|
|
Service Code
|
HCPCS 62321
|
| Hospital Charge Code |
762321
|
|
Hospital Revenue Code
|
964
|
| Min. Negotiated Rate |
$385.70 |
| Max. Negotiated Rate |
$551.00 |
| Rate for Payer: Aetna Commercial |
$523.45
|
| Rate for Payer: Aetna Medicare |
$495.90
|
| Rate for Payer: BCBS MT CHIP |
$495.90
|
| Rate for Payer: BCBS MT Closed Plan Network |
$523.45
|
| Rate for Payer: BCBS MT HealthLink |
$495.90
|
| Rate for Payer: BCBS MT Medicare |
$495.90
|
| Rate for Payer: BCBS MT POS |
$523.45
|
| Rate for Payer: BCBS MT Traditional |
$551.00
|
| Rate for Payer: Cash Price |
$495.90
|
| Rate for Payer: Cigna Commercial |
$523.45
|
| Rate for Payer: Cigna Medicare |
$495.90
|
| Rate for Payer: Medicaid All Medicaid |
$506.92
|
| Rate for Payer: Medicare All Medicare |
$385.70
|
| Rate for Payer: Monida Allegiance |
$523.45
|
| Rate for Payer: Monida First Choice Health |
$534.47
|
| Rate for Payer: Monida Montana Health Co-op |
$523.45
|
| Rate for Payer: Monida PacificSource |
$523.45
|
|
|
PRO FEE OP INJ INTERLAM LUMB W/IMA 62323
|
Professional
|
Both
|
$510.00
|
|
|
Service Code
|
HCPCS 62323
|
| Hospital Charge Code |
762323
|
|
Hospital Revenue Code
|
964
|
| Min. Negotiated Rate |
$357.00 |
| Max. Negotiated Rate |
$510.00 |
| Rate for Payer: Aetna Commercial |
$484.50
|
| Rate for Payer: Aetna Medicare |
$459.00
|
| Rate for Payer: BCBS MT CHIP |
$459.00
|
| Rate for Payer: BCBS MT Closed Plan Network |
$484.50
|
| Rate for Payer: BCBS MT HealthLink |
$459.00
|
| Rate for Payer: BCBS MT Medicare |
$459.00
|
| Rate for Payer: BCBS MT POS |
$484.50
|
| Rate for Payer: BCBS MT Traditional |
$510.00
|
| Rate for Payer: Cash Price |
$459.00
|
| Rate for Payer: Cigna Commercial |
$484.50
|
| Rate for Payer: Cigna Medicare |
$459.00
|
| Rate for Payer: Medicaid All Medicaid |
$469.20
|
| Rate for Payer: Medicare All Medicare |
$357.00
|
| Rate for Payer: Monida Allegiance |
$484.50
|
| Rate for Payer: Monida First Choice Health |
$494.70
|
| Rate for Payer: Monida Montana Health Co-op |
$484.50
|
| Rate for Payer: Monida PacificSource |
$484.50
|
|
|
PRO FEE OP INJ PERIPHERAL NERVE BLOCK
|
Professional
|
Both
|
$213.00
|
|
|
Service Code
|
HCPCS 64450
|
| Hospital Charge Code |
764450
|
|
Hospital Revenue Code
|
964
|
| Min. Negotiated Rate |
$149.10 |
| Max. Negotiated Rate |
$213.00 |
| Rate for Payer: Aetna Commercial |
$202.35
|
| Rate for Payer: Aetna Medicare |
$191.70
|
| Rate for Payer: BCBS MT CHIP |
$191.70
|
| Rate for Payer: BCBS MT Closed Plan Network |
$202.35
|
| Rate for Payer: BCBS MT HealthLink |
$191.70
|
| Rate for Payer: BCBS MT Medicare |
$191.70
|
| Rate for Payer: BCBS MT POS |
$202.35
|
| Rate for Payer: BCBS MT Traditional |
$213.00
|
| Rate for Payer: Cash Price |
$191.70
|
| Rate for Payer: Cigna Commercial |
$202.35
|
| Rate for Payer: Cigna Medicare |
$191.70
|
| Rate for Payer: Medicaid All Medicaid |
$195.96
|
| Rate for Payer: Medicare All Medicare |
$149.10
|
| Rate for Payer: Monida Allegiance |
$202.35
|
| Rate for Payer: Monida First Choice Health |
$206.61
|
| Rate for Payer: Monida Montana Health Co-op |
$202.35
|
| Rate for Payer: Monida PacificSource |
$202.35
|
|
|
PRO FEE OP INJ PLANTAR NERVE BLOCK 64455
|
Professional
|
Both
|
$169.00
|
|
|
Service Code
|
HCPCS 64455
|
| Hospital Charge Code |
764455
|
|
Hospital Revenue Code
|
964
|
| Min. Negotiated Rate |
$118.30 |
| Max. Negotiated Rate |
$169.00 |
| Rate for Payer: Aetna Commercial |
$160.55
|
| Rate for Payer: Aetna Medicare |
$152.10
|
| Rate for Payer: BCBS MT CHIP |
$152.10
|
| Rate for Payer: BCBS MT Closed Plan Network |
$160.55
|
| Rate for Payer: BCBS MT HealthLink |
$152.10
|
| Rate for Payer: BCBS MT Medicare |
$152.10
|
| Rate for Payer: BCBS MT POS |
$160.55
|
| Rate for Payer: BCBS MT Traditional |
$169.00
|
| Rate for Payer: Cash Price |
$152.10
|
| Rate for Payer: Cigna Commercial |
$160.55
|
| Rate for Payer: Cigna Medicare |
$152.10
|
| Rate for Payer: Medicaid All Medicaid |
$155.48
|
| Rate for Payer: Medicare All Medicare |
$118.30
|
| Rate for Payer: Monida Allegiance |
$160.55
|
| Rate for Payer: Monida First Choice Health |
$163.93
|
| Rate for Payer: Monida Montana Health Co-op |
$160.55
|
| Rate for Payer: Monida PacificSource |
$160.55
|
|
|
PRO FEE OP INJ RFA L/S 1ST JOINT 64635
|
Professional
|
Both
|
$993.00
|
|
|
Service Code
|
HCPCS 64635
|
| Hospital Charge Code |
764635
|
|
Hospital Revenue Code
|
964
|
| Min. Negotiated Rate |
$695.10 |
| Max. Negotiated Rate |
$993.00 |
| Rate for Payer: Aetna Commercial |
$943.35
|
| Rate for Payer: Aetna Medicare |
$893.70
|
| Rate for Payer: BCBS MT CHIP |
$893.70
|
| Rate for Payer: BCBS MT Closed Plan Network |
$943.35
|
| Rate for Payer: BCBS MT HealthLink |
$893.70
|
| Rate for Payer: BCBS MT Medicare |
$893.70
|
| Rate for Payer: BCBS MT POS |
$943.35
|
| Rate for Payer: BCBS MT Traditional |
$993.00
|
| Rate for Payer: Cash Price |
$893.70
|
| Rate for Payer: Cigna Commercial |
$943.35
|
| Rate for Payer: Cigna Medicare |
$893.70
|
| Rate for Payer: Medicaid All Medicaid |
$913.56
|
| Rate for Payer: Medicare All Medicare |
$695.10
|
| Rate for Payer: Monida Allegiance |
$943.35
|
| Rate for Payer: Monida First Choice Health |
$963.21
|
| Rate for Payer: Monida Montana Health Co-op |
$943.35
|
| Rate for Payer: Monida PacificSource |
$943.35
|
|
|
PRO FEE OP INJ RFA L/S EADD JOINT 64636
|
Professional
|
Both
|
$302.00
|
|
|
Service Code
|
HCPCS 64636
|
| Hospital Charge Code |
764636
|
|
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 OP INJ SCIATIC NERVE BLOCK 64445
|
Professional
|
Both
|
$370.00
|
|
|
Service Code
|
HCPCS 64445
|
| Hospital Charge Code |
764445
|
|
Hospital Revenue Code
|
964
|
| Min. Negotiated Rate |
$259.00 |
| Max. Negotiated Rate |
$370.00 |
| Rate for Payer: Aetna Commercial |
$351.50
|
| Rate for Payer: Aetna Medicare |
$333.00
|
| Rate for Payer: BCBS MT CHIP |
$333.00
|
| Rate for Payer: BCBS MT Closed Plan Network |
$351.50
|
| Rate for Payer: BCBS MT HealthLink |
$333.00
|
| Rate for Payer: BCBS MT Medicare |
$333.00
|
| Rate for Payer: BCBS MT POS |
$351.50
|
| Rate for Payer: BCBS MT Traditional |
$370.00
|
| Rate for Payer: Cash Price |
$333.00
|
| Rate for Payer: Cigna Commercial |
$351.50
|
| Rate for Payer: Cigna Medicare |
$333.00
|
| Rate for Payer: Medicaid All Medicaid |
$340.40
|
| Rate for Payer: Medicare All Medicare |
$259.00
|
| Rate for Payer: Monida Allegiance |
$351.50
|
| Rate for Payer: Monida First Choice Health |
$358.90
|
| Rate for Payer: Monida Montana Health Co-op |
$351.50
|
| Rate for Payer: Monida PacificSource |
$351.50
|
|
