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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
$732.45 / $753.65 / $3,741.87
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,102.59 / $1,102.59 / $1,102.59
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$843.36 / $1,102.59 / $1,196.01
Providence
Facility/Professional
Facility
Modifier
Low / Median / High Price
$545.29 / $1,350.70 / $1,374.42
Providence
Facility/Professional
Professional
Modifier
Low / Median / High Price
$669.00 / $1,003.60 / $1,447.60
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,059.78 / $1,238.40 / $1,923.99