|
MR FOOT RT W CONTRAST
|
Facility
|
OP
|
$2,495.00
|
|
|
Service Code
|
HCPCS 73719 TC,RT
|
| Hospital Charge Code |
5300042
|
|
Hospital Revenue Code
|
614
|
| Min. Negotiated Rate |
$1,746.50 |
| Max. Negotiated Rate |
$2,495.00 |
| Rate for Payer: Aetna Commercial |
$2,370.25
|
| Rate for Payer: Aetna Medicare |
$2,245.50
|
| Rate for Payer: BCBS MT CHIP |
$2,245.50
|
| Rate for Payer: BCBS MT Closed Plan Network |
$2,370.25
|
| Rate for Payer: BCBS MT HealthLink |
$2,245.50
|
| Rate for Payer: BCBS MT Medicare |
$2,245.50
|
| Rate for Payer: BCBS MT POS |
$2,370.25
|
| Rate for Payer: BCBS MT Traditional |
$2,495.00
|
| Rate for Payer: Cash Price |
$2,245.50
|
| Rate for Payer: Cigna Commercial |
$2,370.25
|
| Rate for Payer: Cigna Medicare |
$2,245.50
|
| Rate for Payer: Medicaid All Medicaid |
$2,295.40
|
| Rate for Payer: Medicare All Medicare |
$1,746.50
|
| Rate for Payer: Monida Allegiance |
$2,370.25
|
| Rate for Payer: Monida First Choice Health |
$2,420.15
|
| Rate for Payer: Monida Montana Health Co-op |
$2,370.25
|
| Rate for Payer: Monida PacificSource |
$2,370.25
|
|
|
MR FOOT RT WO CONTRAST
|
Facility
|
OP
|
$2,255.00
|
|
|
Service Code
|
HCPCS 73718 TC,RT
|
| Hospital Charge Code |
5300048
|
|
Hospital Revenue Code
|
614
|
| Min. Negotiated Rate |
$1,578.50 |
| Max. Negotiated Rate |
$2,255.00 |
| Rate for Payer: Aetna Commercial |
$2,142.25
|
| Rate for Payer: Aetna Medicare |
$2,029.50
|
| Rate for Payer: BCBS MT CHIP |
$2,029.50
|
| Rate for Payer: BCBS MT Closed Plan Network |
$2,142.25
|
| Rate for Payer: BCBS MT HealthLink |
$2,029.50
|
| Rate for Payer: BCBS MT Medicare |
$2,029.50
|
| Rate for Payer: BCBS MT POS |
$2,142.25
|
| Rate for Payer: BCBS MT Traditional |
$2,255.00
|
| Rate for Payer: Cash Price |
$2,029.50
|
| Rate for Payer: Cigna Commercial |
$2,142.25
|
| Rate for Payer: Cigna Medicare |
$2,029.50
|
| Rate for Payer: Medicaid All Medicaid |
$2,074.60
|
| Rate for Payer: Medicare All Medicare |
$1,578.50
|
| Rate for Payer: Monida Allegiance |
$2,142.25
|
| Rate for Payer: Monida First Choice Health |
$2,187.35
|
| Rate for Payer: Monida Montana Health Co-op |
$2,142.25
|
| Rate for Payer: Monida PacificSource |
$2,142.25
|
|
|
MR FOOT RT WO CONTRAST
|
Facility
|
IP
|
$2,255.00
|
|
|
Service Code
|
HCPCS 73718 TC,RT
|
| Hospital Charge Code |
5300048
|
|
Hospital Revenue Code
|
614
|
| Min. Negotiated Rate |
$1,578.50 |
| Max. Negotiated Rate |
$2,255.00 |
| Rate for Payer: Aetna Commercial |
$2,142.25
|
| Rate for Payer: Aetna Medicare |
$2,029.50
|
| Rate for Payer: BCBS MT CHIP |
$2,029.50
|
| Rate for Payer: BCBS MT Closed Plan Network |
$2,142.25
|
| Rate for Payer: BCBS MT HealthLink |
$2,029.50
|
| Rate for Payer: BCBS MT Medicare |
$2,029.50
|
| Rate for Payer: BCBS MT POS |
$2,142.25
|
| Rate for Payer: BCBS MT Traditional |
$2,255.00
|
| Rate for Payer: Cash Price |
$2,029.50
|
| Rate for Payer: Cigna Commercial |
$2,142.25
|
| Rate for Payer: Cigna Medicare |
$2,029.50
|
| Rate for Payer: Medicaid All Medicaid |
$2,074.60
|
| Rate for Payer: Medicare All Medicare |
$1,578.50
|
| Rate for Payer: Monida Allegiance |
$2,142.25
|
| Rate for Payer: Monida First Choice Health |
$2,187.35
|
| Rate for Payer: Monida Montana Health Co-op |
$2,142.25
|
| Rate for Payer: Monida PacificSource |
$2,142.25
|
|
|
MR FOOT RT W WO CONTRAST
|
Facility
|
OP
|
$3,167.00
|
|
|
Service Code
|
HCPCS 73720 TC,RT
|
| Hospital Charge Code |
5300054
|
|
Hospital Revenue Code
|
614
|
| Min. Negotiated Rate |
$2,216.90 |
| Max. Negotiated Rate |
$3,167.00 |
| Rate for Payer: Aetna Commercial |
$3,008.65
|
| Rate for Payer: Aetna Medicare |
$2,850.30
|
| Rate for Payer: BCBS MT CHIP |
$2,850.30
|
| Rate for Payer: BCBS MT Closed Plan Network |
$3,008.65
|
| Rate for Payer: BCBS MT HealthLink |
$2,850.30
|
| Rate for Payer: BCBS MT Medicare |
$2,850.30
|
| Rate for Payer: BCBS MT POS |
$3,008.65
|
| Rate for Payer: BCBS MT Traditional |
$3,167.00
|
| Rate for Payer: Cash Price |
$2,850.30
|
| Rate for Payer: Cigna Commercial |
$3,008.65
|
| Rate for Payer: Cigna Medicare |
$2,850.30
|
| Rate for Payer: Medicaid All Medicaid |
$2,913.64
|
| Rate for Payer: Medicare All Medicare |
$2,216.90
|
| Rate for Payer: Monida Allegiance |
$3,008.65
|
| Rate for Payer: Monida First Choice Health |
$3,071.99
|
| Rate for Payer: Monida Montana Health Co-op |
$3,008.65
|
| Rate for Payer: Monida PacificSource |
$3,008.65
|
|
|
MR FOOT RT W WO CONTRAST
|
Facility
|
IP
|
$3,167.00
|
|
|
Service Code
|
HCPCS 73720 TC,RT
|
| Hospital Charge Code |
5300054
|
|
Hospital Revenue Code
|
614
|
| Min. Negotiated Rate |
$2,216.90 |
| Max. Negotiated Rate |
$3,167.00 |
| Rate for Payer: Aetna Commercial |
$3,008.65
|
| Rate for Payer: Aetna Medicare |
$2,850.30
|
| Rate for Payer: BCBS MT CHIP |
$2,850.30
|
| Rate for Payer: BCBS MT Closed Plan Network |
$3,008.65
|
| Rate for Payer: BCBS MT HealthLink |
$2,850.30
|
| Rate for Payer: BCBS MT Medicare |
$2,850.30
|
| Rate for Payer: BCBS MT POS |
$3,008.65
|
| Rate for Payer: BCBS MT Traditional |
$3,167.00
|
| Rate for Payer: Cash Price |
$2,850.30
|
| Rate for Payer: Cigna Commercial |
$3,008.65
|
| Rate for Payer: Cigna Medicare |
$2,850.30
|
| Rate for Payer: Medicaid All Medicaid |
$2,913.64
|
| Rate for Payer: Medicare All Medicare |
$2,216.90
|
| Rate for Payer: Monida Allegiance |
$3,008.65
|
| Rate for Payer: Monida First Choice Health |
$3,071.99
|
| Rate for Payer: Monida Montana Health Co-op |
$3,008.65
|
| Rate for Payer: Monida PacificSource |
$3,008.65
|
|
|
MR FOREARM LT W CONTRAST
|
Facility
|
IP
|
$2,752.00
|
|
|
Service Code
|
HCPCS 73219 TC,LT
|
| Hospital Charge Code |
5300056
|
|
Hospital Revenue Code
|
614
|
| Min. Negotiated Rate |
$1,926.40 |
| Max. Negotiated Rate |
$2,752.00 |
| Rate for Payer: Aetna Commercial |
$2,614.40
|
| Rate for Payer: Aetna Medicare |
$2,476.80
|
| Rate for Payer: BCBS MT CHIP |
$2,476.80
|
| Rate for Payer: BCBS MT Closed Plan Network |
$2,614.40
|
| Rate for Payer: BCBS MT HealthLink |
$2,476.80
|
| Rate for Payer: BCBS MT Medicare |
$2,476.80
|
| Rate for Payer: BCBS MT POS |
$2,614.40
|
| Rate for Payer: BCBS MT Traditional |
$2,752.00
|
| Rate for Payer: Cash Price |
$2,476.80
|
| Rate for Payer: Cigna Commercial |
$2,614.40
|
| Rate for Payer: Cigna Medicare |
$2,476.80
|
| Rate for Payer: Medicaid All Medicaid |
$2,531.84
|
| Rate for Payer: Medicare All Medicare |
$1,926.40
|
| Rate for Payer: Monida Allegiance |
$2,614.40
|
| Rate for Payer: Monida First Choice Health |
$2,669.44
|
| Rate for Payer: Monida Montana Health Co-op |
$2,614.40
|
| Rate for Payer: Monida PacificSource |
$2,614.40
|
|
|
MR FOREARM LT W CONTRAST
|
Facility
|
OP
|
$2,752.00
|
|
|
Service Code
|
HCPCS 73219 TC,LT
|
| Hospital Charge Code |
5300056
|
|
Hospital Revenue Code
|
614
|
| Min. Negotiated Rate |
$1,926.40 |
| Max. Negotiated Rate |
$2,752.00 |
| Rate for Payer: Aetna Commercial |
$2,614.40
|
| Rate for Payer: Aetna Medicare |
$2,476.80
|
| Rate for Payer: BCBS MT CHIP |
$2,476.80
|
| Rate for Payer: BCBS MT Closed Plan Network |
$2,614.40
|
| Rate for Payer: BCBS MT HealthLink |
$2,476.80
|
| Rate for Payer: BCBS MT Medicare |
$2,476.80
|
| Rate for Payer: BCBS MT POS |
$2,614.40
|
| Rate for Payer: BCBS MT Traditional |
$2,752.00
|
| Rate for Payer: Cash Price |
$2,476.80
|
| Rate for Payer: Cigna Commercial |
$2,614.40
|
| Rate for Payer: Cigna Medicare |
$2,476.80
|
| Rate for Payer: Medicaid All Medicaid |
$2,531.84
|
| Rate for Payer: Medicare All Medicare |
$1,926.40
|
| Rate for Payer: Monida Allegiance |
$2,614.40
|
| Rate for Payer: Monida First Choice Health |
$2,669.44
|
| Rate for Payer: Monida Montana Health Co-op |
$2,614.40
|
| Rate for Payer: Monida PacificSource |
$2,614.40
|
|
|
MR FOREARM LT WO CONTRAST
|
Facility
|
OP
|
$2,222.00
|
|
|
Service Code
|
HCPCS 73218 TC,LT
|
| Hospital Charge Code |
5300062
|
|
Hospital Revenue Code
|
614
|
| Min. Negotiated Rate |
$1,555.40 |
| Max. Negotiated Rate |
$2,222.00 |
| Rate for Payer: Aetna Commercial |
$2,110.90
|
| Rate for Payer: Aetna Medicare |
$1,999.80
|
| Rate for Payer: BCBS MT CHIP |
$1,999.80
|
| Rate for Payer: BCBS MT Closed Plan Network |
$2,110.90
|
| Rate for Payer: BCBS MT HealthLink |
$1,999.80
|
| Rate for Payer: BCBS MT Medicare |
$1,999.80
|
| Rate for Payer: BCBS MT POS |
$2,110.90
|
| Rate for Payer: BCBS MT Traditional |
$2,222.00
|
| Rate for Payer: Cash Price |
$1,999.80
|
| Rate for Payer: Cigna Commercial |
$2,110.90
|
| Rate for Payer: Cigna Medicare |
$1,999.80
|
| Rate for Payer: Medicaid All Medicaid |
$2,044.24
|
| Rate for Payer: Medicare All Medicare |
$1,555.40
|
| Rate for Payer: Monida Allegiance |
$2,110.90
|
| Rate for Payer: Monida First Choice Health |
$2,155.34
|
| Rate for Payer: Monida Montana Health Co-op |
$2,110.90
|
| Rate for Payer: Monida PacificSource |
$2,110.90
|
|
|
MR FOREARM LT WO CONTRAST
|
Facility
|
IP
|
$2,222.00
|
|
|
Service Code
|
HCPCS 73218 TC,LT
|
| Hospital Charge Code |
5300062
|
|
Hospital Revenue Code
|
614
|
| Min. Negotiated Rate |
$1,555.40 |
| Max. Negotiated Rate |
$2,222.00 |
| Rate for Payer: Aetna Commercial |
$2,110.90
|
| Rate for Payer: Aetna Medicare |
$1,999.80
|
| Rate for Payer: BCBS MT CHIP |
$1,999.80
|
| Rate for Payer: BCBS MT Closed Plan Network |
$2,110.90
|
| Rate for Payer: BCBS MT HealthLink |
$1,999.80
|
| Rate for Payer: BCBS MT Medicare |
$1,999.80
|
| Rate for Payer: BCBS MT POS |
$2,110.90
|
| Rate for Payer: BCBS MT Traditional |
$2,222.00
|
| Rate for Payer: Cash Price |
$1,999.80
|
| Rate for Payer: Cigna Commercial |
$2,110.90
|
| Rate for Payer: Cigna Medicare |
$1,999.80
|
| Rate for Payer: Medicaid All Medicaid |
$2,044.24
|
| Rate for Payer: Medicare All Medicare |
$1,555.40
|
| Rate for Payer: Monida Allegiance |
$2,110.90
|
| Rate for Payer: Monida First Choice Health |
$2,155.34
|
| Rate for Payer: Monida Montana Health Co-op |
$2,110.90
|
| Rate for Payer: Monida PacificSource |
$2,110.90
|
|
|
MR FOREARM LT W WO CONTRAST
|
Facility
|
IP
|
$3,172.00
|
|
|
Service Code
|
HCPCS 73220 TC,LT
|
| Hospital Charge Code |
5300075
|
|
Hospital Revenue Code
|
614
|
| Min. Negotiated Rate |
$2,220.40 |
| Max. Negotiated Rate |
$3,172.00 |
| Rate for Payer: Aetna Commercial |
$3,013.40
|
| Rate for Payer: Aetna Medicare |
$2,854.80
|
| Rate for Payer: BCBS MT CHIP |
$2,854.80
|
| Rate for Payer: BCBS MT Closed Plan Network |
$3,013.40
|
| Rate for Payer: BCBS MT HealthLink |
$2,854.80
|
| Rate for Payer: BCBS MT Medicare |
$2,854.80
|
| Rate for Payer: BCBS MT POS |
$3,013.40
|
| Rate for Payer: BCBS MT Traditional |
$3,172.00
|
| Rate for Payer: Cash Price |
$2,854.80
|
| Rate for Payer: Cigna Commercial |
$3,013.40
|
| Rate for Payer: Cigna Medicare |
$2,854.80
|
| Rate for Payer: Medicaid All Medicaid |
$2,918.24
|
| Rate for Payer: Medicare All Medicare |
$2,220.40
|
| Rate for Payer: Monida Allegiance |
$3,013.40
|
| Rate for Payer: Monida First Choice Health |
$3,076.84
|
| Rate for Payer: Monida Montana Health Co-op |
$3,013.40
|
| Rate for Payer: Monida PacificSource |
$3,013.40
|
|
|
MR FOREARM LT W WO CONTRAST
|
Facility
|
OP
|
$3,172.00
|
|
|
Service Code
|
HCPCS 73220 TC,LT
|
| Hospital Charge Code |
5300075
|
|
Hospital Revenue Code
|
614
|
| Min. Negotiated Rate |
$2,220.40 |
| Max. Negotiated Rate |
$3,172.00 |
| Rate for Payer: Aetna Commercial |
$3,013.40
|
| Rate for Payer: Aetna Medicare |
$2,854.80
|
| Rate for Payer: BCBS MT CHIP |
$2,854.80
|
| Rate for Payer: BCBS MT Closed Plan Network |
$3,013.40
|
| Rate for Payer: BCBS MT HealthLink |
$2,854.80
|
| Rate for Payer: BCBS MT Medicare |
$2,854.80
|
| Rate for Payer: BCBS MT POS |
$3,013.40
|
| Rate for Payer: BCBS MT Traditional |
$3,172.00
|
| Rate for Payer: Cash Price |
$2,854.80
|
| Rate for Payer: Cigna Commercial |
$3,013.40
|
| Rate for Payer: Cigna Medicare |
$2,854.80
|
| Rate for Payer: Medicaid All Medicaid |
$2,918.24
|
| Rate for Payer: Medicare All Medicare |
$2,220.40
|
| Rate for Payer: Monida Allegiance |
$3,013.40
|
| Rate for Payer: Monida First Choice Health |
$3,076.84
|
| Rate for Payer: Monida Montana Health Co-op |
$3,013.40
|
| Rate for Payer: Monida PacificSource |
$3,013.40
|
|
|
MR FOREARM RT W CONTRAST
|
Facility
|
OP
|
$2,752.00
|
|
|
Service Code
|
HCPCS 73219 TC,RT
|
| Hospital Charge Code |
5300059
|
|
Hospital Revenue Code
|
614
|
| Min. Negotiated Rate |
$1,926.40 |
| Max. Negotiated Rate |
$2,752.00 |
| Rate for Payer: Aetna Commercial |
$2,614.40
|
| Rate for Payer: Aetna Medicare |
$2,476.80
|
| Rate for Payer: BCBS MT CHIP |
$2,476.80
|
| Rate for Payer: BCBS MT Closed Plan Network |
$2,614.40
|
| Rate for Payer: BCBS MT HealthLink |
$2,476.80
|
| Rate for Payer: BCBS MT Medicare |
$2,476.80
|
| Rate for Payer: BCBS MT POS |
$2,614.40
|
| Rate for Payer: BCBS MT Traditional |
$2,752.00
|
| Rate for Payer: Cash Price |
$2,476.80
|
| Rate for Payer: Cigna Commercial |
$2,614.40
|
| Rate for Payer: Cigna Medicare |
$2,476.80
|
| Rate for Payer: Medicaid All Medicaid |
$2,531.84
|
| Rate for Payer: Medicare All Medicare |
$1,926.40
|
| Rate for Payer: Monida Allegiance |
$2,614.40
|
| Rate for Payer: Monida First Choice Health |
$2,669.44
|
| Rate for Payer: Monida Montana Health Co-op |
$2,614.40
|
| Rate for Payer: Monida PacificSource |
$2,614.40
|
|
|
MR FOREARM RT W CONTRAST
|
Facility
|
IP
|
$2,752.00
|
|
|
Service Code
|
HCPCS 73219 TC,RT
|
| Hospital Charge Code |
5300059
|
|
Hospital Revenue Code
|
614
|
| Min. Negotiated Rate |
$1,926.40 |
| Max. Negotiated Rate |
$2,752.00 |
| Rate for Payer: Aetna Commercial |
$2,614.40
|
| Rate for Payer: Aetna Medicare |
$2,476.80
|
| Rate for Payer: BCBS MT CHIP |
$2,476.80
|
| Rate for Payer: BCBS MT Closed Plan Network |
$2,614.40
|
| Rate for Payer: BCBS MT HealthLink |
$2,476.80
|
| Rate for Payer: BCBS MT Medicare |
$2,476.80
|
| Rate for Payer: BCBS MT POS |
$2,614.40
|
| Rate for Payer: BCBS MT Traditional |
$2,752.00
|
| Rate for Payer: Cash Price |
$2,476.80
|
| Rate for Payer: Cigna Commercial |
$2,614.40
|
| Rate for Payer: Cigna Medicare |
$2,476.80
|
| Rate for Payer: Medicaid All Medicaid |
$2,531.84
|
| Rate for Payer: Medicare All Medicare |
$1,926.40
|
| Rate for Payer: Monida Allegiance |
$2,614.40
|
| Rate for Payer: Monida First Choice Health |
$2,669.44
|
| Rate for Payer: Monida Montana Health Co-op |
$2,614.40
|
| Rate for Payer: Monida PacificSource |
$2,614.40
|
|
|
MR FOREARM RT WO CONTRAST
|
Facility
|
IP
|
$2,222.00
|
|
|
Service Code
|
HCPCS 73218 TC,RT
|
| Hospital Charge Code |
5300070
|
|
Hospital Revenue Code
|
614
|
| Min. Negotiated Rate |
$1,555.40 |
| Max. Negotiated Rate |
$2,222.00 |
| Rate for Payer: Aetna Commercial |
$2,110.90
|
| Rate for Payer: Aetna Medicare |
$1,999.80
|
| Rate for Payer: BCBS MT CHIP |
$1,999.80
|
| Rate for Payer: BCBS MT Closed Plan Network |
$2,110.90
|
| Rate for Payer: BCBS MT HealthLink |
$1,999.80
|
| Rate for Payer: BCBS MT Medicare |
$1,999.80
|
| Rate for Payer: BCBS MT POS |
$2,110.90
|
| Rate for Payer: BCBS MT Traditional |
$2,222.00
|
| Rate for Payer: Cash Price |
$1,999.80
|
| Rate for Payer: Cigna Commercial |
$2,110.90
|
| Rate for Payer: Cigna Medicare |
$1,999.80
|
| Rate for Payer: Medicaid All Medicaid |
$2,044.24
|
| Rate for Payer: Medicare All Medicare |
$1,555.40
|
| Rate for Payer: Monida Allegiance |
$2,110.90
|
| Rate for Payer: Monida First Choice Health |
$2,155.34
|
| Rate for Payer: Monida Montana Health Co-op |
$2,110.90
|
| Rate for Payer: Monida PacificSource |
$2,110.90
|
|
|
MR FOREARM RT WO CONTRAST
|
Facility
|
OP
|
$2,222.00
|
|
|
Service Code
|
HCPCS 73218 TC,RT
|
| Hospital Charge Code |
5300070
|
|
Hospital Revenue Code
|
614
|
| Min. Negotiated Rate |
$1,555.40 |
| Max. Negotiated Rate |
$2,222.00 |
| Rate for Payer: Aetna Commercial |
$2,110.90
|
| Rate for Payer: Aetna Medicare |
$1,999.80
|
| Rate for Payer: BCBS MT CHIP |
$1,999.80
|
| Rate for Payer: BCBS MT Closed Plan Network |
$2,110.90
|
| Rate for Payer: BCBS MT HealthLink |
$1,999.80
|
| Rate for Payer: BCBS MT Medicare |
$1,999.80
|
| Rate for Payer: BCBS MT POS |
$2,110.90
|
| Rate for Payer: BCBS MT Traditional |
$2,222.00
|
| Rate for Payer: Cash Price |
$1,999.80
|
| Rate for Payer: Cigna Commercial |
$2,110.90
|
| Rate for Payer: Cigna Medicare |
$1,999.80
|
| Rate for Payer: Medicaid All Medicaid |
$2,044.24
|
| Rate for Payer: Medicare All Medicare |
$1,555.40
|
| Rate for Payer: Monida Allegiance |
$2,110.90
|
| Rate for Payer: Monida First Choice Health |
$2,155.34
|
| Rate for Payer: Monida Montana Health Co-op |
$2,110.90
|
| Rate for Payer: Monida PacificSource |
$2,110.90
|
|
|
MR FOREARM RT W WO CONTRAST
|
Facility
|
IP
|
$3,172.00
|
|
|
Service Code
|
HCPCS 73220 TC,RT
|
| Hospital Charge Code |
5300129
|
|
Hospital Revenue Code
|
614
|
| Min. Negotiated Rate |
$2,220.40 |
| Max. Negotiated Rate |
$3,172.00 |
| Rate for Payer: Aetna Commercial |
$3,013.40
|
| Rate for Payer: Aetna Medicare |
$2,854.80
|
| Rate for Payer: BCBS MT CHIP |
$2,854.80
|
| Rate for Payer: BCBS MT Closed Plan Network |
$3,013.40
|
| Rate for Payer: BCBS MT HealthLink |
$2,854.80
|
| Rate for Payer: BCBS MT Medicare |
$2,854.80
|
| Rate for Payer: BCBS MT POS |
$3,013.40
|
| Rate for Payer: BCBS MT Traditional |
$3,172.00
|
| Rate for Payer: Cash Price |
$2,854.80
|
| Rate for Payer: Cigna Commercial |
$3,013.40
|
| Rate for Payer: Cigna Medicare |
$2,854.80
|
| Rate for Payer: Medicaid All Medicaid |
$2,918.24
|
| Rate for Payer: Medicare All Medicare |
$2,220.40
|
| Rate for Payer: Monida Allegiance |
$3,013.40
|
| Rate for Payer: Monida First Choice Health |
$3,076.84
|
| Rate for Payer: Monida Montana Health Co-op |
$3,013.40
|
| Rate for Payer: Monida PacificSource |
$3,013.40
|
|
|
MR FOREARM RT W WO CONTRAST
|
Facility
|
OP
|
$3,172.00
|
|
|
Service Code
|
HCPCS 73220 TC,RT
|
| Hospital Charge Code |
5300129
|
|
Hospital Revenue Code
|
614
|
| Min. Negotiated Rate |
$2,220.40 |
| Max. Negotiated Rate |
$3,172.00 |
| Rate for Payer: Aetna Commercial |
$3,013.40
|
| Rate for Payer: Aetna Medicare |
$2,854.80
|
| Rate for Payer: BCBS MT CHIP |
$2,854.80
|
| Rate for Payer: BCBS MT Closed Plan Network |
$3,013.40
|
| Rate for Payer: BCBS MT HealthLink |
$2,854.80
|
| Rate for Payer: BCBS MT Medicare |
$2,854.80
|
| Rate for Payer: BCBS MT POS |
$3,013.40
|
| Rate for Payer: BCBS MT Traditional |
$3,172.00
|
| Rate for Payer: Cash Price |
$2,854.80
|
| Rate for Payer: Cigna Commercial |
$3,013.40
|
| Rate for Payer: Cigna Medicare |
$2,854.80
|
| Rate for Payer: Medicaid All Medicaid |
$2,918.24
|
| Rate for Payer: Medicare All Medicare |
$2,220.40
|
| Rate for Payer: Monida Allegiance |
$3,013.40
|
| Rate for Payer: Monida First Choice Health |
$3,076.84
|
| Rate for Payer: Monida Montana Health Co-op |
$3,013.40
|
| Rate for Payer: Monida PacificSource |
$3,013.40
|
|
|
MR HAND LT W CONTRAST
|
Facility
|
IP
|
$2,752.00
|
|
|
Service Code
|
HCPCS 73219 TC,LT
|
| Hospital Charge Code |
5300057
|
|
Hospital Revenue Code
|
614
|
| Min. Negotiated Rate |
$1,926.40 |
| Max. Negotiated Rate |
$2,752.00 |
| Rate for Payer: Aetna Commercial |
$2,614.40
|
| Rate for Payer: Aetna Medicare |
$2,476.80
|
| Rate for Payer: BCBS MT CHIP |
$2,476.80
|
| Rate for Payer: BCBS MT Closed Plan Network |
$2,614.40
|
| Rate for Payer: BCBS MT HealthLink |
$2,476.80
|
| Rate for Payer: BCBS MT Medicare |
$2,476.80
|
| Rate for Payer: BCBS MT POS |
$2,614.40
|
| Rate for Payer: BCBS MT Traditional |
$2,752.00
|
| Rate for Payer: Cash Price |
$2,476.80
|
| Rate for Payer: Cigna Commercial |
$2,614.40
|
| Rate for Payer: Cigna Medicare |
$2,476.80
|
| Rate for Payer: Medicaid All Medicaid |
$2,531.84
|
| Rate for Payer: Medicare All Medicare |
$1,926.40
|
| Rate for Payer: Monida Allegiance |
$2,614.40
|
| Rate for Payer: Monida First Choice Health |
$2,669.44
|
| Rate for Payer: Monida Montana Health Co-op |
$2,614.40
|
| Rate for Payer: Monida PacificSource |
$2,614.40
|
|
|
MR HAND LT W CONTRAST
|
Facility
|
OP
|
$2,752.00
|
|
|
Service Code
|
HCPCS 73219 TC,LT
|
| Hospital Charge Code |
5300057
|
|
Hospital Revenue Code
|
614
|
| Min. Negotiated Rate |
$1,926.40 |
| Max. Negotiated Rate |
$2,752.00 |
| Rate for Payer: Aetna Commercial |
$2,614.40
|
| Rate for Payer: Aetna Medicare |
$2,476.80
|
| Rate for Payer: BCBS MT CHIP |
$2,476.80
|
| Rate for Payer: BCBS MT Closed Plan Network |
$2,614.40
|
| Rate for Payer: BCBS MT HealthLink |
$2,476.80
|
| Rate for Payer: BCBS MT Medicare |
$2,476.80
|
| Rate for Payer: BCBS MT POS |
$2,614.40
|
| Rate for Payer: BCBS MT Traditional |
$2,752.00
|
| Rate for Payer: Cash Price |
$2,476.80
|
| Rate for Payer: Cigna Commercial |
$2,614.40
|
| Rate for Payer: Cigna Medicare |
$2,476.80
|
| Rate for Payer: Medicaid All Medicaid |
$2,531.84
|
| Rate for Payer: Medicare All Medicare |
$1,926.40
|
| Rate for Payer: Monida Allegiance |
$2,614.40
|
| Rate for Payer: Monida First Choice Health |
$2,669.44
|
| Rate for Payer: Monida Montana Health Co-op |
$2,614.40
|
| Rate for Payer: Monida PacificSource |
$2,614.40
|
|
|
MR HAND LT WO CONTRAST
|
Facility
|
IP
|
$2,222.00
|
|
|
Service Code
|
HCPCS 73218 TC,LT
|
| Hospital Charge Code |
5300063
|
|
Hospital Revenue Code
|
614
|
| Min. Negotiated Rate |
$1,555.40 |
| Max. Negotiated Rate |
$2,222.00 |
| Rate for Payer: Aetna Commercial |
$2,110.90
|
| Rate for Payer: Aetna Medicare |
$1,999.80
|
| Rate for Payer: BCBS MT CHIP |
$1,999.80
|
| Rate for Payer: BCBS MT Closed Plan Network |
$2,110.90
|
| Rate for Payer: BCBS MT HealthLink |
$1,999.80
|
| Rate for Payer: BCBS MT Medicare |
$1,999.80
|
| Rate for Payer: BCBS MT POS |
$2,110.90
|
| Rate for Payer: BCBS MT Traditional |
$2,222.00
|
| Rate for Payer: Cash Price |
$1,999.80
|
| Rate for Payer: Cigna Commercial |
$2,110.90
|
| Rate for Payer: Cigna Medicare |
$1,999.80
|
| Rate for Payer: Medicaid All Medicaid |
$2,044.24
|
| Rate for Payer: Medicare All Medicare |
$1,555.40
|
| Rate for Payer: Monida Allegiance |
$2,110.90
|
| Rate for Payer: Monida First Choice Health |
$2,155.34
|
| Rate for Payer: Monida Montana Health Co-op |
$2,110.90
|
| Rate for Payer: Monida PacificSource |
$2,110.90
|
|
|
MR HAND LT WO CONTRAST
|
Facility
|
OP
|
$2,222.00
|
|
|
Service Code
|
HCPCS 73218 TC,LT
|
| Hospital Charge Code |
5300063
|
|
Hospital Revenue Code
|
614
|
| Min. Negotiated Rate |
$1,555.40 |
| Max. Negotiated Rate |
$2,222.00 |
| Rate for Payer: Aetna Commercial |
$2,110.90
|
| Rate for Payer: Aetna Medicare |
$1,999.80
|
| Rate for Payer: BCBS MT CHIP |
$1,999.80
|
| Rate for Payer: BCBS MT Closed Plan Network |
$2,110.90
|
| Rate for Payer: BCBS MT HealthLink |
$1,999.80
|
| Rate for Payer: BCBS MT Medicare |
$1,999.80
|
| Rate for Payer: BCBS MT POS |
$2,110.90
|
| Rate for Payer: BCBS MT Traditional |
$2,222.00
|
| Rate for Payer: Cash Price |
$1,999.80
|
| Rate for Payer: Cigna Commercial |
$2,110.90
|
| Rate for Payer: Cigna Medicare |
$1,999.80
|
| Rate for Payer: Medicaid All Medicaid |
$2,044.24
|
| Rate for Payer: Medicare All Medicare |
$1,555.40
|
| Rate for Payer: Monida Allegiance |
$2,110.90
|
| Rate for Payer: Monida First Choice Health |
$2,155.34
|
| Rate for Payer: Monida Montana Health Co-op |
$2,110.90
|
| Rate for Payer: Monida PacificSource |
$2,110.90
|
|
|
MR HAND LT W WO CONTRAST
|
Facility
|
OP
|
$3,172.00
|
|
|
Service Code
|
HCPCS 73220 TC,LT
|
| Hospital Charge Code |
5300127
|
|
Hospital Revenue Code
|
614
|
| Min. Negotiated Rate |
$2,220.40 |
| Max. Negotiated Rate |
$3,172.00 |
| Rate for Payer: Aetna Commercial |
$3,013.40
|
| Rate for Payer: Aetna Medicare |
$2,854.80
|
| Rate for Payer: BCBS MT CHIP |
$2,854.80
|
| Rate for Payer: BCBS MT Closed Plan Network |
$3,013.40
|
| Rate for Payer: BCBS MT HealthLink |
$2,854.80
|
| Rate for Payer: BCBS MT Medicare |
$2,854.80
|
| Rate for Payer: BCBS MT POS |
$3,013.40
|
| Rate for Payer: BCBS MT Traditional |
$3,172.00
|
| Rate for Payer: Cash Price |
$2,854.80
|
| Rate for Payer: Cigna Commercial |
$3,013.40
|
| Rate for Payer: Cigna Medicare |
$2,854.80
|
| Rate for Payer: Medicaid All Medicaid |
$2,918.24
|
| Rate for Payer: Medicare All Medicare |
$2,220.40
|
| Rate for Payer: Monida Allegiance |
$3,013.40
|
| Rate for Payer: Monida First Choice Health |
$3,076.84
|
| Rate for Payer: Monida Montana Health Co-op |
$3,013.40
|
| Rate for Payer: Monida PacificSource |
$3,013.40
|
|
|
MR HAND LT W WO CONTRAST
|
Facility
|
IP
|
$3,172.00
|
|
|
Service Code
|
HCPCS 73220 TC,LT
|
| Hospital Charge Code |
5300127
|
|
Hospital Revenue Code
|
614
|
| Min. Negotiated Rate |
$2,220.40 |
| Max. Negotiated Rate |
$3,172.00 |
| Rate for Payer: Aetna Commercial |
$3,013.40
|
| Rate for Payer: Aetna Medicare |
$2,854.80
|
| Rate for Payer: BCBS MT CHIP |
$2,854.80
|
| Rate for Payer: BCBS MT Closed Plan Network |
$3,013.40
|
| Rate for Payer: BCBS MT HealthLink |
$2,854.80
|
| Rate for Payer: BCBS MT Medicare |
$2,854.80
|
| Rate for Payer: BCBS MT POS |
$3,013.40
|
| Rate for Payer: BCBS MT Traditional |
$3,172.00
|
| Rate for Payer: Cash Price |
$2,854.80
|
| Rate for Payer: Cigna Commercial |
$3,013.40
|
| Rate for Payer: Cigna Medicare |
$2,854.80
|
| Rate for Payer: Medicaid All Medicaid |
$2,918.24
|
| Rate for Payer: Medicare All Medicare |
$2,220.40
|
| Rate for Payer: Monida Allegiance |
$3,013.40
|
| Rate for Payer: Monida First Choice Health |
$3,076.84
|
| Rate for Payer: Monida Montana Health Co-op |
$3,013.40
|
| Rate for Payer: Monida PacificSource |
$3,013.40
|
|
|
MR HAND RT W CONTRAST
|
Facility
|
OP
|
$2,752.00
|
|
|
Service Code
|
HCPCS 73219 TC,RT
|
| Hospital Charge Code |
5300060
|
|
Hospital Revenue Code
|
614
|
| Min. Negotiated Rate |
$1,926.40 |
| Max. Negotiated Rate |
$2,752.00 |
| Rate for Payer: Aetna Commercial |
$2,614.40
|
| Rate for Payer: Aetna Medicare |
$2,476.80
|
| Rate for Payer: BCBS MT CHIP |
$2,476.80
|
| Rate for Payer: BCBS MT Closed Plan Network |
$2,614.40
|
| Rate for Payer: BCBS MT HealthLink |
$2,476.80
|
| Rate for Payer: BCBS MT Medicare |
$2,476.80
|
| Rate for Payer: BCBS MT POS |
$2,614.40
|
| Rate for Payer: BCBS MT Traditional |
$2,752.00
|
| Rate for Payer: Cash Price |
$2,476.80
|
| Rate for Payer: Cigna Commercial |
$2,614.40
|
| Rate for Payer: Cigna Medicare |
$2,476.80
|
| Rate for Payer: Medicaid All Medicaid |
$2,531.84
|
| Rate for Payer: Medicare All Medicare |
$1,926.40
|
| Rate for Payer: Monida Allegiance |
$2,614.40
|
| Rate for Payer: Monida First Choice Health |
$2,669.44
|
| Rate for Payer: Monida Montana Health Co-op |
$2,614.40
|
| Rate for Payer: Monida PacificSource |
$2,614.40
|
|
|
MR HAND RT W CONTRAST
|
Facility
|
IP
|
$2,752.00
|
|
|
Service Code
|
HCPCS 73219 TC,RT
|
| Hospital Charge Code |
5300060
|
|
Hospital Revenue Code
|
614
|
| Min. Negotiated Rate |
$1,926.40 |
| Max. Negotiated Rate |
$2,752.00 |
| Rate for Payer: Aetna Commercial |
$2,614.40
|
| Rate for Payer: Aetna Medicare |
$2,476.80
|
| Rate for Payer: BCBS MT CHIP |
$2,476.80
|
| Rate for Payer: BCBS MT Closed Plan Network |
$2,614.40
|
| Rate for Payer: BCBS MT HealthLink |
$2,476.80
|
| Rate for Payer: BCBS MT Medicare |
$2,476.80
|
| Rate for Payer: BCBS MT POS |
$2,614.40
|
| Rate for Payer: BCBS MT Traditional |
$2,752.00
|
| Rate for Payer: Cash Price |
$2,476.80
|
| Rate for Payer: Cigna Commercial |
$2,614.40
|
| Rate for Payer: Cigna Medicare |
$2,476.80
|
| Rate for Payer: Medicaid All Medicaid |
$2,531.84
|
| Rate for Payer: Medicare All Medicare |
$1,926.40
|
| Rate for Payer: Monida Allegiance |
$2,614.40
|
| Rate for Payer: Monida First Choice Health |
$2,669.44
|
| Rate for Payer: Monida Montana Health Co-op |
$2,614.40
|
| Rate for Payer: Monida PacificSource |
$2,614.40
|
|
