|
PRO FEE OP INJ FACET JNT C/T 3RDL 64492
|
Professional
|
Both
|
$307.00
|
|
|
Service Code
|
CPT 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
|
CPT 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
|
CPT 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
|
CPT 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
|
CPT 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
|
CPT 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
|
CPT 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
|
CPT 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
|
CPT 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
|
CPT 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
|
CPT 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
|
CPT 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
|
CPT 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
|
|
|
PRO FEE OP INJ SI JOINT W/IMAGE 27096
|
Professional
|
Both
|
$430.00
|
|
|
Service Code
|
CPT 27096
|
| Hospital Charge Code |
727096
|
|
Hospital Revenue Code
|
964
|
| Min. Negotiated Rate |
$301.00 |
| Max. Negotiated Rate |
$430.00 |
| Rate for Payer: Aetna Commercial |
$408.50
|
| Rate for Payer: Aetna Medicare |
$387.00
|
| Rate for Payer: BCBS MT CHIP |
$387.00
|
| Rate for Payer: BCBS MT Closed Plan Network |
$408.50
|
| Rate for Payer: BCBS MT HealthLink |
$387.00
|
| Rate for Payer: BCBS MT Medicare |
$387.00
|
| Rate for Payer: BCBS MT POS |
$408.50
|
| Rate for Payer: BCBS MT Traditional |
$430.00
|
| Rate for Payer: Cash Price |
$387.00
|
| Rate for Payer: Cigna Commercial |
$408.50
|
| Rate for Payer: Cigna Medicare |
$387.00
|
| Rate for Payer: Medicaid All Medicaid |
$395.60
|
| Rate for Payer: Medicare All Medicare |
$301.00
|
| Rate for Payer: Monida Allegiance |
$408.50
|
| Rate for Payer: Monida First Choice Health |
$417.10
|
| Rate for Payer: Monida Montana Health Co-op |
$408.50
|
| Rate for Payer: Monida PacificSource |
$408.50
|
|
|
PRO FEE OP INJ SPHENOPALGANG BLOC 64505
|
Professional
|
Both
|
$554.00
|
|
|
Service Code
|
CPT 64505
|
| Hospital Charge Code |
764505
|
|
Hospital Revenue Code
|
964
|
| Min. Negotiated Rate |
$387.80 |
| Max. Negotiated Rate |
$554.00 |
| Rate for Payer: Aetna Commercial |
$526.30
|
| Rate for Payer: Aetna Medicare |
$498.60
|
| Rate for Payer: BCBS MT CHIP |
$498.60
|
| Rate for Payer: BCBS MT Closed Plan Network |
$526.30
|
| Rate for Payer: BCBS MT HealthLink |
$498.60
|
| Rate for Payer: BCBS MT Medicare |
$498.60
|
| Rate for Payer: BCBS MT POS |
$526.30
|
| Rate for Payer: BCBS MT Traditional |
$554.00
|
| Rate for Payer: Cash Price |
$498.60
|
| Rate for Payer: Cigna Commercial |
$526.30
|
| Rate for Payer: Cigna Medicare |
$498.60
|
| Rate for Payer: Medicaid All Medicaid |
$509.68
|
| Rate for Payer: Medicare All Medicare |
$387.80
|
| Rate for Payer: Monida Allegiance |
$526.30
|
| Rate for Payer: Monida First Choice Health |
$537.38
|
| Rate for Payer: Monida Montana Health Co-op |
$526.30
|
| Rate for Payer: Monida PacificSource |
$526.30
|
|
|
PRO FEE OP INJ STELLATE GANG BLOCK 64510
|
Professional
|
Both
|
$395.00
|
|
|
Service Code
|
CPT 64510
|
| Hospital Charge Code |
764510
|
|
Hospital Revenue Code
|
964
|
| Min. Negotiated Rate |
$276.50 |
| Max. Negotiated Rate |
$395.00 |
| Rate for Payer: Aetna Commercial |
$375.25
|
| Rate for Payer: Aetna Medicare |
$355.50
|
| Rate for Payer: BCBS MT CHIP |
$355.50
|
| Rate for Payer: BCBS MT Closed Plan Network |
$375.25
|
| Rate for Payer: BCBS MT HealthLink |
$355.50
|
| Rate for Payer: BCBS MT Medicare |
$355.50
|
| Rate for Payer: BCBS MT POS |
$375.25
|
| Rate for Payer: BCBS MT Traditional |
$395.00
|
| Rate for Payer: Cash Price |
$355.50
|
| Rate for Payer: Cigna Commercial |
$375.25
|
| Rate for Payer: Cigna Medicare |
$355.50
|
| Rate for Payer: Medicaid All Medicaid |
$363.40
|
| Rate for Payer: Medicare All Medicare |
$276.50
|
| Rate for Payer: Monida Allegiance |
$375.25
|
| Rate for Payer: Monida First Choice Health |
$383.15
|
| Rate for Payer: Monida Montana Health Co-op |
$375.25
|
| Rate for Payer: Monida PacificSource |
$375.25
|
|
|
PRO FEE OP INJ SUPER HYPOGSTRC PLX 64517
|
Professional
|
Both
|
$654.00
|
|
|
Service Code
|
CPT 64517
|
| Hospital Charge Code |
764517
|
|
Hospital Revenue Code
|
964
|
| Min. Negotiated Rate |
$457.80 |
| Max. Negotiated Rate |
$654.00 |
| Rate for Payer: Aetna Commercial |
$621.30
|
| Rate for Payer: Aetna Medicare |
$588.60
|
| Rate for Payer: BCBS MT CHIP |
$588.60
|
| Rate for Payer: BCBS MT Closed Plan Network |
$621.30
|
| Rate for Payer: BCBS MT HealthLink |
$588.60
|
| Rate for Payer: BCBS MT Medicare |
$588.60
|
| Rate for Payer: BCBS MT POS |
$621.30
|
| Rate for Payer: BCBS MT Traditional |
$654.00
|
| Rate for Payer: Cash Price |
$588.60
|
| Rate for Payer: Cigna Commercial |
$621.30
|
| Rate for Payer: Cigna Medicare |
$588.60
|
| Rate for Payer: Medicaid All Medicaid |
$601.68
|
| Rate for Payer: Medicare All Medicare |
$457.80
|
| Rate for Payer: Monida Allegiance |
$621.30
|
| Rate for Payer: Monida First Choice Health |
$634.38
|
| Rate for Payer: Monida Montana Health Co-op |
$621.30
|
| Rate for Payer: Monida PacificSource |
$621.30
|
|
|
PRO FEE OP INJ SUPRASCAP NERVE 764418
|
Professional
|
Both
|
$284.00
|
|
|
Service Code
|
CPT 64418
|
| Hospital Charge Code |
764418
|
|
Hospital Revenue Code
|
964
|
| Min. Negotiated Rate |
$198.80 |
| Max. Negotiated Rate |
$284.00 |
| Rate for Payer: Aetna Commercial |
$269.80
|
| Rate for Payer: Aetna Medicare |
$255.60
|
| Rate for Payer: BCBS MT CHIP |
$255.60
|
| Rate for Payer: BCBS MT Closed Plan Network |
$269.80
|
| Rate for Payer: BCBS MT HealthLink |
$255.60
|
| Rate for Payer: BCBS MT Medicare |
$255.60
|
| Rate for Payer: BCBS MT POS |
$269.80
|
| Rate for Payer: BCBS MT Traditional |
$284.00
|
| Rate for Payer: Cash Price |
$255.60
|
| Rate for Payer: Cigna Commercial |
$269.80
|
| Rate for Payer: Cigna Medicare |
$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 OP INJ TRANFOR C/T ADDTL 64480
|
Professional
|
Both
|
$316.00
|
|
|
Service Code
|
CPT 64480
|
| Hospital Charge Code |
764480
|
|
Hospital Revenue Code
|
964
|
| 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 OP INJ TRANSFORA L/S 1 64483
|
Professional
|
Both
|
$573.00
|
|
|
Service Code
|
CPT 64483
|
| Hospital Charge Code |
764483
|
|
Hospital Revenue Code
|
964
|
| Min. Negotiated Rate |
$401.10 |
| Max. Negotiated Rate |
$573.00 |
| Rate for Payer: Aetna Commercial |
$544.35
|
| Rate for Payer: Aetna Medicare |
$515.70
|
| Rate for Payer: BCBS MT CHIP |
$515.70
|
| Rate for Payer: BCBS MT Closed Plan Network |
$544.35
|
| Rate for Payer: BCBS MT HealthLink |
$515.70
|
| Rate for Payer: BCBS MT Medicare |
$515.70
|
| Rate for Payer: BCBS MT POS |
$544.35
|
| Rate for Payer: BCBS MT Traditional |
$573.00
|
| Rate for Payer: Cash Price |
$515.70
|
| Rate for Payer: Cigna Commercial |
$544.35
|
| Rate for Payer: Cigna Medicare |
$515.70
|
| Rate for Payer: Medicaid All Medicaid |
$527.16
|
| Rate for Payer: Medicare All Medicare |
$401.10
|
| Rate for Payer: Monida Allegiance |
$544.35
|
| Rate for Payer: Monida First Choice Health |
$555.81
|
| Rate for Payer: Monida Montana Health Co-op |
$544.35
|
| Rate for Payer: Monida PacificSource |
$544.35
|
|
|
PRO FEE OP INSERTION PICC LINE 36569
|
Professional
|
Both
|
$457.00
|
|
|
Service Code
|
CPT 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
|
$304.00
|
|
|
Service Code
|
CPT 20611
|
| Hospital Charge Code |
720611
|
|
Hospital Revenue Code
|
964
|
| Min. Negotiated Rate |
$212.80 |
| Max. Negotiated Rate |
$304.00 |
| Rate for Payer: Aetna Commercial |
$288.80
|
| Rate for Payer: Aetna Medicare |
$273.60
|
| Rate for Payer: BCBS MT CHIP |
$273.60
|
| Rate for Payer: BCBS MT Closed Plan Network |
$288.80
|
| Rate for Payer: BCBS MT HealthLink |
$273.60
|
| Rate for Payer: BCBS MT Medicare |
$273.60
|
| Rate for Payer: BCBS MT POS |
$288.80
|
| Rate for Payer: BCBS MT Traditional |
$304.00
|
| Rate for Payer: Cash Price |
$273.60
|
| Rate for Payer: Cigna Commercial |
$288.80
|
| Rate for Payer: Cigna Medicare |
$273.60
|
| Rate for Payer: Medicaid All Medicaid |
$279.68
|
| Rate for Payer: Medicare All Medicare |
$212.80
|
| Rate for Payer: Monida Allegiance |
$288.80
|
| Rate for Payer: Monida First Choice Health |
$294.88
|
| Rate for Payer: Monida Montana Health Co-op |
$288.80
|
| Rate for Payer: Monida PacificSource |
$288.80
|
|
|
PRO FEE OPO HIGH
|
Professional
|
Both
|
$483.00
|
|
|
Service Code
|
CPT 99223
|
| Hospital Charge Code |
799220
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$338.10 |
| Max. Negotiated Rate |
$468.51 |
| Rate for Payer: Aetna Commercial |
$458.85
|
| Rate for Payer: Aetna Medicare |
$434.70
|
| Rate for Payer: Cash Price |
$434.70
|
| Rate for Payer: Medicaid All Medicaid |
$444.36
|
| Rate for Payer: Medicare All Medicare |
$338.10
|
| Rate for Payer: Monida Allegiance |
$458.85
|
| Rate for Payer: Monida First Choice Health |
$468.51
|
| Rate for Payer: Monida Montana Health Co-op |
$458.85
|
| Rate for Payer: Monida PacificSource |
$458.85
|
|
|
PRO FEE OPO LOW (99221)
|
Professional
|
Both
|
$230.00
|
|
|
Service Code
|
CPT 99221
|
| Hospital Charge Code |
799218
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$161.00 |
| Max. Negotiated Rate |
$223.10 |
| Rate for Payer: Aetna Commercial |
$218.50
|
| Rate for Payer: Aetna Medicare |
$207.00
|
| Rate for Payer: Cash Price |
$207.00
|
| Rate for Payer: Medicaid All Medicaid |
$211.60
|
| Rate for Payer: Medicare All Medicare |
$161.00
|
| Rate for Payer: Monida Allegiance |
$218.50
|
| Rate for Payer: Monida First Choice Health |
$223.10
|
| Rate for Payer: Monida Montana Health Co-op |
$218.50
|
| Rate for Payer: Monida PacificSource |
$218.50
|
|
|
PRO FEE OPO MODERATE
|
Professional
|
Both
|
$363.00
|
|
|
Service Code
|
CPT 99222
|
| Hospital Charge Code |
799219
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$254.10 |
| Max. Negotiated Rate |
$352.11 |
| Rate for Payer: Aetna Commercial |
$344.85
|
| Rate for Payer: Aetna Medicare |
$326.70
|
| Rate for Payer: Cash Price |
$326.70
|
| Rate for Payer: Medicaid All Medicaid |
$333.96
|
| Rate for Payer: Medicare All Medicare |
$254.10
|
| Rate for Payer: Monida Allegiance |
$344.85
|
| Rate for Payer: Monida First Choice Health |
$352.11
|
| Rate for Payer: Monida Montana Health Co-op |
$344.85
|
| Rate for Payer: Monida PacificSource |
$344.85
|
|
