|
PRO FEE REPAIR SIMPLE S/N/A/G/T/E12.6-20
|
Professional
|
Both
|
$177.00
|
|
|
Service Code
|
CPT 12005
|
| Hospital Charge Code |
712005
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$123.90 |
| Max. Negotiated Rate |
$177.00 |
| Rate for Payer: Aetna Commercial |
$168.15
|
| Rate for Payer: Aetna Medicare |
$159.30
|
| Rate for Payer: BCBS MT CHIP |
$159.30
|
| Rate for Payer: BCBS MT Closed Plan Network |
$168.15
|
| Rate for Payer: BCBS MT HealthLink |
$159.30
|
| Rate for Payer: BCBS MT Medicare |
$159.30
|
| Rate for Payer: BCBS MT POS |
$168.15
|
| Rate for Payer: BCBS MT Traditional |
$177.00
|
| Rate for Payer: Cash Price |
$159.30
|
| Rate for Payer: Cigna Commercial |
$168.15
|
| Rate for Payer: Cigna Medicare |
$159.30
|
| Rate for Payer: Medicaid All Medicaid |
$162.84
|
| Rate for Payer: Medicare All Medicare |
$123.90
|
| Rate for Payer: Monida Allegiance |
$168.15
|
| Rate for Payer: Monida First Choice Health |
$171.69
|
| Rate for Payer: Monida Montana Health Co-op |
$168.15
|
| Rate for Payer: Monida PacificSource |
$168.15
|
|
|
PRO FEE REPAIR S/N/AX/G/T >30CM
|
Professional
|
Both
|
$272.00
|
|
|
Service Code
|
CPT 12007
|
| Hospital Charge Code |
782007
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$190.40 |
| Max. Negotiated Rate |
$272.00 |
| Rate for Payer: Aetna Commercial |
$258.40
|
| Rate for Payer: Aetna Medicare |
$244.80
|
| Rate for Payer: BCBS MT CHIP |
$244.80
|
| Rate for Payer: BCBS MT Closed Plan Network |
$258.40
|
| Rate for Payer: BCBS MT HealthLink |
$244.80
|
| Rate for Payer: BCBS MT Medicare |
$244.80
|
| Rate for Payer: BCBS MT POS |
$258.40
|
| Rate for Payer: BCBS MT Traditional |
$272.00
|
| Rate for Payer: Cash Price |
$244.80
|
| Rate for Payer: Cigna Commercial |
$258.40
|
| Rate for Payer: Cigna Medicare |
$244.80
|
| Rate for Payer: Medicaid All Medicaid |
$250.24
|
| Rate for Payer: Medicare All Medicare |
$190.40
|
| Rate for Payer: Monida Allegiance |
$258.40
|
| Rate for Payer: Monida First Choice Health |
$263.84
|
| Rate for Payer: Monida Montana Health Co-op |
$258.40
|
| Rate for Payer: Monida PacificSource |
$258.40
|
|
|
PRO FEE REPAIR WOUND COMPLEX 1.1-2.5CM
|
Professional
|
Both
|
$461.00
|
|
|
Service Code
|
CPT 13131
|
| Hospital Charge Code |
713131
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$322.70 |
| Max. Negotiated Rate |
$461.00 |
| Rate for Payer: Aetna Commercial |
$437.95
|
| Rate for Payer: Aetna Medicare |
$414.90
|
| Rate for Payer: BCBS MT CHIP |
$414.90
|
| Rate for Payer: BCBS MT Closed Plan Network |
$437.95
|
| Rate for Payer: BCBS MT HealthLink |
$414.90
|
| Rate for Payer: BCBS MT Medicare |
$414.90
|
| Rate for Payer: BCBS MT POS |
$437.95
|
| Rate for Payer: BCBS MT Traditional |
$461.00
|
| Rate for Payer: Cash Price |
$414.90
|
| Rate for Payer: Cigna Commercial |
$437.95
|
| Rate for Payer: Cigna Medicare |
$414.90
|
| Rate for Payer: Medicaid All Medicaid |
$424.12
|
| Rate for Payer: Medicare All Medicare |
$322.70
|
| Rate for Payer: Monida Allegiance |
$437.95
|
| Rate for Payer: Monida First Choice Health |
$447.17
|
| Rate for Payer: Monida Montana Health Co-op |
$437.95
|
| Rate for Payer: Monida PacificSource |
$437.95
|
|
|
PRO FEE REPAIR WOUND INT=< 2.5
|
Professional
|
Both
|
$324.00
|
|
|
Service Code
|
CPT 12051
|
| Hospital Charge Code |
712051
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$226.80 |
| Max. Negotiated Rate |
$324.00 |
| Rate for Payer: Aetna Commercial |
$307.80
|
| Rate for Payer: Aetna Medicare |
$291.60
|
| Rate for Payer: BCBS MT CHIP |
$291.60
|
| Rate for Payer: BCBS MT Closed Plan Network |
$307.80
|
| Rate for Payer: BCBS MT HealthLink |
$291.60
|
| Rate for Payer: BCBS MT Medicare |
$291.60
|
| Rate for Payer: BCBS MT POS |
$307.80
|
| Rate for Payer: BCBS MT Traditional |
$324.00
|
| Rate for Payer: Cash Price |
$291.60
|
| Rate for Payer: Cigna Commercial |
$307.80
|
| Rate for Payer: Cigna Medicare |
$291.60
|
| Rate for Payer: Medicaid All Medicaid |
$298.08
|
| Rate for Payer: Medicare All Medicare |
$226.80
|
| Rate for Payer: Monida Allegiance |
$307.80
|
| Rate for Payer: Monida First Choice Health |
$314.28
|
| Rate for Payer: Monida Montana Health Co-op |
$307.80
|
| Rate for Payer: Monida PacificSource |
$307.80
|
|
|
PRO FEE REPAIR WOUND SIMPLE 2.5CM/LESS
|
Professional
|
Both
|
$105.00
|
|
|
Service Code
|
CPT 12011
|
| Hospital Charge Code |
712011
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$73.50 |
| Max. Negotiated Rate |
$105.00 |
| Rate for Payer: Aetna Commercial |
$99.75
|
| Rate for Payer: Aetna Medicare |
$94.50
|
| Rate for Payer: BCBS MT CHIP |
$94.50
|
| Rate for Payer: BCBS MT Closed Plan Network |
$99.75
|
| Rate for Payer: BCBS MT HealthLink |
$94.50
|
| Rate for Payer: BCBS MT Medicare |
$94.50
|
| Rate for Payer: BCBS MT POS |
$99.75
|
| Rate for Payer: BCBS MT Traditional |
$105.00
|
| Rate for Payer: Cash Price |
$94.50
|
| Rate for Payer: Cigna Commercial |
$99.75
|
| Rate for Payer: Cigna Medicare |
$94.50
|
| Rate for Payer: Medicaid All Medicaid |
$96.60
|
| Rate for Payer: Medicare All Medicare |
$73.50
|
| Rate for Payer: Monida Allegiance |
$99.75
|
| Rate for Payer: Monida First Choice Health |
$101.85
|
| Rate for Payer: Monida Montana Health Co-op |
$99.75
|
| Rate for Payer: Monida PacificSource |
$99.75
|
|
|
PRO FEE REPAIR WOUND SIMPLE 2.6-5.0CM
|
Professional
|
Both
|
$109.00
|
|
|
Service Code
|
CPT 12013
|
| Hospital Charge Code |
712013
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$76.30 |
| Max. Negotiated Rate |
$109.00 |
| Rate for Payer: Aetna Commercial |
$103.55
|
| Rate for Payer: Aetna Medicare |
$98.10
|
| Rate for Payer: BCBS MT CHIP |
$98.10
|
| Rate for Payer: BCBS MT Closed Plan Network |
$103.55
|
| Rate for Payer: BCBS MT HealthLink |
$98.10
|
| Rate for Payer: BCBS MT Medicare |
$98.10
|
| Rate for Payer: BCBS MT POS |
$103.55
|
| Rate for Payer: BCBS MT Traditional |
$109.00
|
| Rate for Payer: Cash Price |
$98.10
|
| Rate for Payer: Cigna Commercial |
$103.55
|
| Rate for Payer: Cigna Medicare |
$98.10
|
| Rate for Payer: Medicaid All Medicaid |
$100.28
|
| Rate for Payer: Medicare All Medicare |
$76.30
|
| Rate for Payer: Monida Allegiance |
$103.55
|
| Rate for Payer: Monida First Choice Health |
$105.73
|
| Rate for Payer: Monida Montana Health Co-op |
$103.55
|
| Rate for Payer: Monida PacificSource |
$103.55
|
|
|
PRO FEE REPAIR WOUND SIMPLE 5.1-7.5CM
|
Professional
|
Both
|
$139.00
|
|
|
Service Code
|
CPT 12014
|
| Hospital Charge Code |
712014
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$97.30 |
| Max. Negotiated Rate |
$139.00 |
| Rate for Payer: Aetna Commercial |
$132.05
|
| Rate for Payer: Aetna Medicare |
$125.10
|
| Rate for Payer: BCBS MT CHIP |
$125.10
|
| Rate for Payer: BCBS MT Closed Plan Network |
$132.05
|
| Rate for Payer: BCBS MT HealthLink |
$125.10
|
| Rate for Payer: BCBS MT Medicare |
$125.10
|
| Rate for Payer: BCBS MT POS |
$132.05
|
| Rate for Payer: BCBS MT Traditional |
$139.00
|
| Rate for Payer: Cash Price |
$125.10
|
| Rate for Payer: Cigna Commercial |
$132.05
|
| Rate for Payer: Cigna Medicare |
$125.10
|
| Rate for Payer: Medicaid All Medicaid |
$127.88
|
| Rate for Payer: Medicare All Medicare |
$97.30
|
| Rate for Payer: Monida Allegiance |
$132.05
|
| Rate for Payer: Monida First Choice Health |
$134.83
|
| Rate for Payer: Monida Montana Health Co-op |
$132.05
|
| Rate for Payer: Monida PacificSource |
$132.05
|
|
|
PROFEE RF ABLTJ NRV NRVTG SI JT W/I
|
Professional
|
Both
|
$520.00
|
|
|
Service Code
|
CPT 64625
|
| Hospital Charge Code |
7664625
|
|
Hospital Revenue Code
|
964
|
| Min. Negotiated Rate |
$364.00 |
| Max. Negotiated Rate |
$520.00 |
| Rate for Payer: Aetna Commercial |
$494.00
|
| Rate for Payer: Aetna Medicare |
$468.00
|
| Rate for Payer: BCBS MT CHIP |
$468.00
|
| Rate for Payer: BCBS MT Closed Plan Network |
$494.00
|
| Rate for Payer: BCBS MT HealthLink |
$468.00
|
| Rate for Payer: BCBS MT Medicare |
$468.00
|
| Rate for Payer: BCBS MT POS |
$494.00
|
| Rate for Payer: BCBS MT Traditional |
$520.00
|
| Rate for Payer: Cash Price |
$468.00
|
| Rate for Payer: Cigna Commercial |
$494.00
|
| Rate for Payer: Cigna Medicare |
$468.00
|
| Rate for Payer: Medicaid All Medicaid |
$478.40
|
| Rate for Payer: Medicare All Medicare |
$364.00
|
| Rate for Payer: Monida Allegiance |
$494.00
|
| Rate for Payer: Monida First Choice Health |
$504.40
|
| Rate for Payer: Monida Montana Health Co-op |
$494.00
|
| Rate for Payer: Monida PacificSource |
$494.00
|
|
|
PRO FEE SMALL JOINT INJ W/O US 20600
|
Professional
|
Both
|
$184.00
|
|
|
Service Code
|
CPT 20600
|
| Hospital Charge Code |
720600
|
|
Hospital Revenue Code
|
964
|
| Min. Negotiated Rate |
$128.80 |
| Max. Negotiated Rate |
$184.00 |
| Rate for Payer: Aetna Commercial |
$174.80
|
| Rate for Payer: Aetna Medicare |
$165.60
|
| Rate for Payer: BCBS MT CHIP |
$165.60
|
| Rate for Payer: BCBS MT Closed Plan Network |
$174.80
|
| Rate for Payer: BCBS MT HealthLink |
$165.60
|
| Rate for Payer: BCBS MT Medicare |
$165.60
|
| Rate for Payer: BCBS MT POS |
$174.80
|
| Rate for Payer: BCBS MT Traditional |
$184.00
|
| Rate for Payer: Cash Price |
$165.60
|
| Rate for Payer: Cigna Commercial |
$174.80
|
| Rate for Payer: Cigna Medicare |
$165.60
|
| Rate for Payer: Medicaid All Medicaid |
$169.28
|
| Rate for Payer: Medicare All Medicare |
$128.80
|
| Rate for Payer: Monida Allegiance |
$174.80
|
| Rate for Payer: Monida First Choice Health |
$178.48
|
| Rate for Payer: Monida Montana Health Co-op |
$174.80
|
| Rate for Payer: Monida PacificSource |
$174.80
|
|
|
PRO FEE STRAPPING OF HAND/FINGER
|
Professional
|
Both
|
$101.00
|
|
|
Service Code
|
CPT 29280
|
| Hospital Charge Code |
729280
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$70.70 |
| Max. Negotiated Rate |
$101.00 |
| Rate for Payer: Aetna Commercial |
$95.95
|
| Rate for Payer: Aetna Medicare |
$90.90
|
| Rate for Payer: BCBS MT CHIP |
$90.90
|
| Rate for Payer: BCBS MT Closed Plan Network |
$95.95
|
| Rate for Payer: BCBS MT HealthLink |
$90.90
|
| Rate for Payer: BCBS MT Medicare |
$90.90
|
| Rate for Payer: BCBS MT POS |
$95.95
|
| Rate for Payer: BCBS MT Traditional |
$101.00
|
| Rate for Payer: Cash Price |
$90.90
|
| Rate for Payer: Cigna Commercial |
$95.95
|
| Rate for Payer: Cigna Medicare |
$90.90
|
| Rate for Payer: Medicaid All Medicaid |
$92.92
|
| Rate for Payer: Medicare All Medicare |
$70.70
|
| Rate for Payer: Monida Allegiance |
$95.95
|
| Rate for Payer: Monida First Choice Health |
$97.97
|
| Rate for Payer: Monida Montana Health Co-op |
$95.95
|
| Rate for Payer: Monida PacificSource |
$95.95
|
|
|
PROFEE STRESS ECHO TREADMILL
|
Professional
|
Both
|
$264.00
|
|
|
Service Code
|
CPT 93350
|
| Hospital Charge Code |
50002428
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$184.80 |
| Max. Negotiated Rate |
$256.08 |
| Rate for Payer: Aetna Commercial |
$250.80
|
| Rate for Payer: Aetna Medicare |
$237.60
|
| Rate for Payer: Cash Price |
$237.60
|
| Rate for Payer: Medicaid All Medicaid |
$242.88
|
| Rate for Payer: Medicare All Medicare |
$184.80
|
| Rate for Payer: Monida Allegiance |
$250.80
|
| Rate for Payer: Monida First Choice Health |
$256.08
|
| Rate for Payer: Monida Montana Health Co-op |
$250.80
|
| Rate for Payer: Monida PacificSource |
$250.80
|
|
|
PROFEE TCD STD ICR ART VEN-ART SHNT
|
Professional
|
Both
|
$229.00
|
|
|
Service Code
|
CPT 93893
|
| Hospital Charge Code |
50002433
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$160.30 |
| Max. Negotiated Rate |
$222.13 |
| Rate for Payer: Aetna Commercial |
$217.55
|
| Rate for Payer: Aetna Medicare |
$206.10
|
| Rate for Payer: Cash Price |
$206.10
|
| Rate for Payer: Medicaid All Medicaid |
$210.68
|
| Rate for Payer: Medicare All Medicare |
$160.30
|
| Rate for Payer: Monida Allegiance |
$217.55
|
| Rate for Payer: Monida First Choice Health |
$222.13
|
| Rate for Payer: Monida Montana Health Co-op |
$217.55
|
| Rate for Payer: Monida PacificSource |
$217.55
|
|
|
PRO FEE TRIGGER POINT INJ 3+ 20553
|
Professional
|
Both
|
$213.00
|
|
|
Service Code
|
CPT 20553
|
| Hospital Charge Code |
720553
|
|
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 TRIG PT INJ 1-2 GRPS 20552(SIJ)
|
Professional
|
Both
|
$187.00
|
|
|
Service Code
|
CPT 20552
|
| Hospital Charge Code |
720552
|
|
Hospital Revenue Code
|
964
|
| Min. Negotiated Rate |
$130.90 |
| Max. Negotiated Rate |
$187.00 |
| Rate for Payer: Aetna Commercial |
$177.65
|
| Rate for Payer: Aetna Medicare |
$168.30
|
| Rate for Payer: BCBS MT CHIP |
$168.30
|
| Rate for Payer: BCBS MT Closed Plan Network |
$177.65
|
| Rate for Payer: BCBS MT HealthLink |
$168.30
|
| Rate for Payer: BCBS MT Medicare |
$168.30
|
| Rate for Payer: BCBS MT POS |
$177.65
|
| Rate for Payer: BCBS MT Traditional |
$187.00
|
| Rate for Payer: Cash Price |
$168.30
|
| Rate for Payer: Cigna Commercial |
$177.65
|
| Rate for Payer: Cigna Medicare |
$168.30
|
| Rate for Payer: Medicaid All Medicaid |
$172.04
|
| Rate for Payer: Medicare All Medicare |
$130.90
|
| Rate for Payer: Monida Allegiance |
$177.65
|
| Rate for Payer: Monida First Choice Health |
$181.39
|
| Rate for Payer: Monida Montana Health Co-op |
$177.65
|
| Rate for Payer: Monida PacificSource |
$177.65
|
|
|
PROFEE US 3D REND W/INTERP&POSTPRC DIFF
|
Professional
|
Both
|
$110.00
|
|
|
Service Code
|
CPT 76377
|
| Hospital Charge Code |
50002371
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$77.00 |
| Max. Negotiated Rate |
$106.70 |
| Rate for Payer: Aetna Commercial |
$104.50
|
| Rate for Payer: Aetna Medicare |
$99.00
|
| Rate for Payer: Cash Price |
$99.00
|
| Rate for Payer: Medicaid All Medicaid |
$101.20
|
| Rate for Payer: Medicare All Medicare |
$77.00
|
| Rate for Payer: Monida Allegiance |
$104.50
|
| Rate for Payer: Monida First Choice Health |
$106.70
|
| Rate for Payer: Monida Montana Health Co-op |
$104.50
|
| Rate for Payer: Monida PacificSource |
$104.50
|
|
|
PROFEE US 3D REND W/INTERPRET POST PROCE
|
Professional
|
Both
|
$29.00
|
|
|
Service Code
|
CPT 76376
|
| Hospital Charge Code |
50002372
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$20.30 |
| Max. Negotiated Rate |
$28.13 |
| Rate for Payer: Aetna Commercial |
$27.55
|
| Rate for Payer: Aetna Medicare |
$26.10
|
| Rate for Payer: Cash Price |
$26.10
|
| Rate for Payer: Medicaid All Medicaid |
$26.68
|
| Rate for Payer: Medicare All Medicare |
$20.30
|
| Rate for Payer: Monida Allegiance |
$27.55
|
| Rate for Payer: Monida First Choice Health |
$28.13
|
| Rate for Payer: Monida Montana Health Co-op |
$27.55
|
| Rate for Payer: Monida PacificSource |
$27.55
|
|
|
PROFEE US ABD AORTA REAL TME SCREEN STUD
|
Professional
|
Both
|
$101.00
|
|
|
Service Code
|
CPT 76706
|
| Hospital Charge Code |
50002376
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$70.70 |
| Max. Negotiated Rate |
$97.97 |
| Rate for Payer: Aetna Commercial |
$95.95
|
| Rate for Payer: Aetna Medicare |
$90.90
|
| Rate for Payer: Cash Price |
$90.90
|
| Rate for Payer: Medicaid All Medicaid |
$92.92
|
| Rate for Payer: Medicare All Medicare |
$70.70
|
| Rate for Payer: Monida Allegiance |
$95.95
|
| Rate for Payer: Monida First Choice Health |
$97.97
|
| Rate for Payer: Monida Montana Health Co-op |
$95.95
|
| Rate for Payer: Monida PacificSource |
$95.95
|
|
|
PROFEE US ABDOMEN COMPLETE
|
Professional
|
Both
|
$149.00
|
|
|
Service Code
|
CPT 76700
|
| Hospital Charge Code |
50002373
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$104.30 |
| Max. Negotiated Rate |
$144.53 |
| Rate for Payer: Aetna Commercial |
$141.55
|
| Rate for Payer: Aetna Medicare |
$134.10
|
| Rate for Payer: Cash Price |
$134.10
|
| Rate for Payer: Medicaid All Medicaid |
$137.08
|
| Rate for Payer: Medicare All Medicare |
$104.30
|
| Rate for Payer: Monida Allegiance |
$141.55
|
| Rate for Payer: Monida First Choice Health |
$144.53
|
| Rate for Payer: Monida Montana Health Co-op |
$141.55
|
| Rate for Payer: Monida PacificSource |
$141.55
|
|
|
PROFEE US ABDOMEN DOPP LMT
|
Professional
|
Both
|
$146.00
|
|
|
Service Code
|
CPT 93976
|
| Hospital Charge Code |
50002374
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$102.20 |
| Max. Negotiated Rate |
$141.62 |
| Rate for Payer: Aetna Commercial |
$138.70
|
| Rate for Payer: Aetna Medicare |
$131.40
|
| Rate for Payer: Cash Price |
$131.40
|
| Rate for Payer: Medicaid All Medicaid |
$134.32
|
| Rate for Payer: Medicare All Medicare |
$102.20
|
| Rate for Payer: Monida Allegiance |
$138.70
|
| Rate for Payer: Monida First Choice Health |
$141.62
|
| Rate for Payer: Monida Montana Health Co-op |
$138.70
|
| Rate for Payer: Monida PacificSource |
$138.70
|
|
|
PROFEE US ABDOMEN LIMITED
|
Professional
|
Both
|
$108.00
|
|
|
Service Code
|
CPT 76705
|
| Hospital Charge Code |
50002375
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$75.60 |
| Max. Negotiated Rate |
$104.76 |
| Rate for Payer: Aetna Commercial |
$102.60
|
| Rate for Payer: Aetna Medicare |
$97.20
|
| Rate for Payer: Cash Price |
$97.20
|
| Rate for Payer: Medicaid All Medicaid |
$99.36
|
| Rate for Payer: Medicare All Medicare |
$75.60
|
| Rate for Payer: Monida Allegiance |
$102.60
|
| Rate for Payer: Monida First Choice Health |
$104.76
|
| Rate for Payer: Monida Montana Health Co-op |
$102.60
|
| Rate for Payer: Monida PacificSource |
$102.60
|
|
|
PROFEE US ABI
|
Professional
|
Both
|
$46.00
|
|
|
Service Code
|
CPT 93922
|
| Hospital Charge Code |
50002377
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$32.20 |
| Max. Negotiated Rate |
$44.62 |
| Rate for Payer: Aetna Commercial |
$43.70
|
| Rate for Payer: Aetna Medicare |
$41.40
|
| Rate for Payer: Cash Price |
$41.40
|
| Rate for Payer: Medicaid All Medicaid |
$42.32
|
| Rate for Payer: Medicare All Medicare |
$32.20
|
| Rate for Payer: Monida Allegiance |
$43.70
|
| Rate for Payer: Monida First Choice Health |
$44.62
|
| Rate for Payer: Monida Montana Health Co-op |
$43.70
|
| Rate for Payer: Monida PacificSource |
$43.70
|
|
|
PROFEE US ABSCESS DRAINAGE
|
Professional
|
Both
|
$104.00
|
|
|
Service Code
|
CPT 75989
|
| Hospital Charge Code |
50002420
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$72.80 |
| Max. Negotiated Rate |
$100.88 |
| Rate for Payer: Aetna Commercial |
$98.80
|
| Rate for Payer: Aetna Medicare |
$93.60
|
| Rate for Payer: Cash Price |
$93.60
|
| Rate for Payer: Medicaid All Medicaid |
$95.68
|
| Rate for Payer: Medicare All Medicare |
$72.80
|
| Rate for Payer: Monida Allegiance |
$98.80
|
| Rate for Payer: Monida First Choice Health |
$100.88
|
| Rate for Payer: Monida Montana Health Co-op |
$98.80
|
| Rate for Payer: Monida PacificSource |
$98.80
|
|
|
PROFEE US AORTA SCREEN/MC
|
Professional
|
Both
|
$90.00
|
|
|
Service Code
|
CPT 93979
|
| Hospital Charge Code |
50002378
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$63.00 |
| Max. Negotiated Rate |
$87.30 |
| Rate for Payer: Aetna Commercial |
$85.50
|
| Rate for Payer: Aetna Medicare |
$81.00
|
| Rate for Payer: Cash Price |
$81.00
|
| Rate for Payer: Medicaid All Medicaid |
$82.80
|
| Rate for Payer: Medicare All Medicare |
$63.00
|
| Rate for Payer: Monida Allegiance |
$85.50
|
| Rate for Payer: Monida First Choice Health |
$87.30
|
| Rate for Payer: Monida Montana Health Co-op |
$85.50
|
| Rate for Payer: Monida PacificSource |
$85.50
|
|
|
PROFEE US ARTERY BYPASS GRAFT
|
Professional
|
Both
|
$90.00
|
|
|
Service Code
|
CPT 93979
|
| Hospital Charge Code |
50002379
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$63.00 |
| Max. Negotiated Rate |
$87.30 |
| Rate for Payer: Aetna Commercial |
$85.50
|
| Rate for Payer: Aetna Medicare |
$81.00
|
| Rate for Payer: Cash Price |
$81.00
|
| Rate for Payer: Medicaid All Medicaid |
$82.80
|
| Rate for Payer: Medicare All Medicare |
$63.00
|
| Rate for Payer: Monida Allegiance |
$85.50
|
| Rate for Payer: Monida First Choice Health |
$87.30
|
| Rate for Payer: Monida Montana Health Co-op |
$85.50
|
| Rate for Payer: Monida PacificSource |
$85.50
|
|
|
PROFEE US BLADDER PRE/POST
|
Professional
|
Both
|
$91.00
|
|
|
Service Code
|
CPT 76857
|
| Hospital Charge Code |
50002380
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$63.70 |
| Max. Negotiated Rate |
$88.27 |
| Rate for Payer: Aetna Commercial |
$86.45
|
| Rate for Payer: Aetna Medicare |
$81.90
|
| Rate for Payer: Cash Price |
$81.90
|
| Rate for Payer: Medicaid All Medicaid |
$83.72
|
| Rate for Payer: Medicare All Medicare |
$63.70
|
| Rate for Payer: Monida Allegiance |
$86.45
|
| Rate for Payer: Monida First Choice Health |
$88.27
|
| Rate for Payer: Monida Montana Health Co-op |
$86.45
|
| Rate for Payer: Monida PacificSource |
$86.45
|
|
