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Montana rates for HCPCS 50575

Renal endoscopy through nephrotomy or pyelotomy, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic service; with endopyelotomy (includes cystoscopy, ureteroscopy, dilation of ureter and ureteral pelvic junction, incision of ureteral pelvic junction and insertion of endopyelotomy stent)

Insurance Carrier
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$707.95 / $851.14 / $1,737.80
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,096.48 / $1,096.48 / $1,096.48
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$851.14 / $1,096.48 / $1,202.26
MountainHealth Co-op
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,202.26 / $1,230.27 / $1,479.11
MountainHealth Co-op
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,202.26 / $1,230.27 / $1,479.11
Providence
Facility/Professional
Facility
Modifier
Low / Median / High Price
$616.60 / $1,047.13 / $1,380.38
Providence
Facility/Professional
Professional
Modifier
Low / Median / High Price
$79.43 / $724.44 / $1,445.44
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,071.52 / $1,230.27 / $1,778.28