|
MR LWR EXT W CON RT
|
Facility
|
OP
|
$2,495.00
|
|
|
Service Code
|
HCPCS 73719 TC,RT
|
| Hospital Charge Code |
5300107
|
|
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 LWR XT WO CON LT
|
Facility
|
OP
|
$2,255.00
|
|
|
Service Code
|
HCPCS 73718 TC,LT
|
| Hospital Charge Code |
5300108
|
|
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 LWR XT WO CON LT
|
Facility
|
IP
|
$2,255.00
|
|
|
Service Code
|
HCPCS 73718 TC,LT
|
| Hospital Charge Code |
5300108
|
|
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 LWR XT WO CON RT
|
Facility
|
IP
|
$2,255.00
|
|
|
Service Code
|
HCPCS 73718 TC,RT
|
| Hospital Charge Code |
5300109
|
|
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 LWR XT WO CON RT
|
Facility
|
OP
|
$2,255.00
|
|
|
Service Code
|
HCPCS 73718 TC,RT
|
| Hospital Charge Code |
5300109
|
|
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 LWR XT WO&W CON LT
|
Facility
|
IP
|
$3,167.00
|
|
|
Service Code
|
HCPCS 73720 TC,LT
|
| Hospital Charge Code |
5300110
|
|
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 LWR XT WO&W CON LT
|
Facility
|
OP
|
$3,167.00
|
|
|
Service Code
|
HCPCS 73720 TC,LT
|
| Hospital Charge Code |
5300110
|
|
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 LWR XT WO&W CON RT
|
Facility
|
IP
|
$3,167.00
|
|
|
Service Code
|
HCPCS 73720 TC,RT
|
| Hospital Charge Code |
5300111
|
|
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 LWR XT WO&W CON RT
|
Facility
|
OP
|
$3,167.00
|
|
|
Service Code
|
HCPCS 73720 TC,RT
|
| Hospital Charge Code |
5300111
|
|
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 ORBIT FACE NECK W CONTRAST
|
Facility
|
IP
|
$2,501.00
|
|
|
Service Code
|
HCPCS 70542 TC
|
| Hospital Charge Code |
5300077
|
|
Hospital Revenue Code
|
614
|
| Min. Negotiated Rate |
$1,750.70 |
| Max. Negotiated Rate |
$2,501.00 |
| Rate for Payer: Aetna Commercial |
$2,375.95
|
| Rate for Payer: Aetna Medicare |
$2,250.90
|
| Rate for Payer: BCBS MT CHIP |
$2,250.90
|
| Rate for Payer: BCBS MT Closed Plan Network |
$2,375.95
|
| Rate for Payer: BCBS MT HealthLink |
$2,250.90
|
| Rate for Payer: BCBS MT Medicare |
$2,250.90
|
| Rate for Payer: BCBS MT POS |
$2,375.95
|
| Rate for Payer: BCBS MT Traditional |
$2,501.00
|
| Rate for Payer: Cash Price |
$2,250.90
|
| Rate for Payer: Cigna Commercial |
$2,375.95
|
| Rate for Payer: Cigna Medicare |
$2,250.90
|
| Rate for Payer: Medicaid All Medicaid |
$2,300.92
|
| Rate for Payer: Medicare All Medicare |
$1,750.70
|
| Rate for Payer: Monida Allegiance |
$2,375.95
|
| Rate for Payer: Monida First Choice Health |
$2,425.97
|
| Rate for Payer: Monida Montana Health Co-op |
$2,375.95
|
| Rate for Payer: Monida PacificSource |
$2,375.95
|
|
|
MR ORBIT FACE NECK W CONTRAST
|
Facility
|
OP
|
$2,501.00
|
|
|
Service Code
|
HCPCS 70542 TC
|
| Hospital Charge Code |
5300077
|
|
Hospital Revenue Code
|
614
|
| Min. Negotiated Rate |
$1,750.70 |
| Max. Negotiated Rate |
$2,501.00 |
| Rate for Payer: Aetna Commercial |
$2,375.95
|
| Rate for Payer: Aetna Medicare |
$2,250.90
|
| Rate for Payer: BCBS MT CHIP |
$2,250.90
|
| Rate for Payer: BCBS MT Closed Plan Network |
$2,375.95
|
| Rate for Payer: BCBS MT HealthLink |
$2,250.90
|
| Rate for Payer: BCBS MT Medicare |
$2,250.90
|
| Rate for Payer: BCBS MT POS |
$2,375.95
|
| Rate for Payer: BCBS MT Traditional |
$2,501.00
|
| Rate for Payer: Cash Price |
$2,250.90
|
| Rate for Payer: Cigna Commercial |
$2,375.95
|
| Rate for Payer: Cigna Medicare |
$2,250.90
|
| Rate for Payer: Medicaid All Medicaid |
$2,300.92
|
| Rate for Payer: Medicare All Medicare |
$1,750.70
|
| Rate for Payer: Monida Allegiance |
$2,375.95
|
| Rate for Payer: Monida First Choice Health |
$2,425.97
|
| Rate for Payer: Monida Montana Health Co-op |
$2,375.95
|
| Rate for Payer: Monida PacificSource |
$2,375.95
|
|
|
MR ORBIT FACE NECK WO CONTRAST
|
Facility
|
IP
|
$2,298.00
|
|
|
Service Code
|
HCPCS 70540 TC
|
| Hospital Charge Code |
5300113
|
|
Hospital Revenue Code
|
614
|
| Min. Negotiated Rate |
$1,608.60 |
| Max. Negotiated Rate |
$2,298.00 |
| Rate for Payer: Aetna Commercial |
$2,183.10
|
| Rate for Payer: Aetna Medicare |
$2,068.20
|
| Rate for Payer: BCBS MT CHIP |
$2,068.20
|
| Rate for Payer: BCBS MT Closed Plan Network |
$2,183.10
|
| Rate for Payer: BCBS MT HealthLink |
$2,068.20
|
| Rate for Payer: BCBS MT Medicare |
$2,068.20
|
| Rate for Payer: BCBS MT POS |
$2,183.10
|
| Rate for Payer: BCBS MT Traditional |
$2,298.00
|
| Rate for Payer: Cash Price |
$2,068.20
|
| Rate for Payer: Cigna Commercial |
$2,183.10
|
| Rate for Payer: Cigna Medicare |
$2,068.20
|
| Rate for Payer: Medicaid All Medicaid |
$2,114.16
|
| Rate for Payer: Medicare All Medicare |
$1,608.60
|
| Rate for Payer: Monida Allegiance |
$2,183.10
|
| Rate for Payer: Monida First Choice Health |
$2,229.06
|
| Rate for Payer: Monida Montana Health Co-op |
$2,183.10
|
| Rate for Payer: Monida PacificSource |
$2,183.10
|
|
|
MR ORBIT FACE NECK WO CONTRAST
|
Facility
|
OP
|
$2,298.00
|
|
|
Service Code
|
HCPCS 70540 TC
|
| Hospital Charge Code |
5300113
|
|
Hospital Revenue Code
|
614
|
| Min. Negotiated Rate |
$1,608.60 |
| Max. Negotiated Rate |
$2,298.00 |
| Rate for Payer: Aetna Commercial |
$2,183.10
|
| Rate for Payer: Aetna Medicare |
$2,068.20
|
| Rate for Payer: BCBS MT CHIP |
$2,068.20
|
| Rate for Payer: BCBS MT Closed Plan Network |
$2,183.10
|
| Rate for Payer: BCBS MT HealthLink |
$2,068.20
|
| Rate for Payer: BCBS MT Medicare |
$2,068.20
|
| Rate for Payer: BCBS MT POS |
$2,183.10
|
| Rate for Payer: BCBS MT Traditional |
$2,298.00
|
| Rate for Payer: Cash Price |
$2,068.20
|
| Rate for Payer: Cigna Commercial |
$2,183.10
|
| Rate for Payer: Cigna Medicare |
$2,068.20
|
| Rate for Payer: Medicaid All Medicaid |
$2,114.16
|
| Rate for Payer: Medicare All Medicare |
$1,608.60
|
| Rate for Payer: Monida Allegiance |
$2,183.10
|
| Rate for Payer: Monida First Choice Health |
$2,229.06
|
| Rate for Payer: Monida Montana Health Co-op |
$2,183.10
|
| Rate for Payer: Monida PacificSource |
$2,183.10
|
|
|
MR ORBIT FACE NECK W WO CONTRAST
|
Facility
|
IP
|
$3,281.00
|
|
|
Service Code
|
HCPCS 70543 TC
|
| Hospital Charge Code |
5300112
|
|
Hospital Revenue Code
|
614
|
| Min. Negotiated Rate |
$2,296.70 |
| Max. Negotiated Rate |
$3,281.00 |
| Rate for Payer: Aetna Commercial |
$3,116.95
|
| Rate for Payer: Aetna Medicare |
$2,952.90
|
| Rate for Payer: BCBS MT CHIP |
$2,952.90
|
| Rate for Payer: BCBS MT Closed Plan Network |
$3,116.95
|
| Rate for Payer: BCBS MT HealthLink |
$2,952.90
|
| Rate for Payer: BCBS MT Medicare |
$2,952.90
|
| Rate for Payer: BCBS MT POS |
$3,116.95
|
| Rate for Payer: BCBS MT Traditional |
$3,281.00
|
| Rate for Payer: Cash Price |
$2,952.90
|
| Rate for Payer: Cigna Commercial |
$3,116.95
|
| Rate for Payer: Cigna Medicare |
$2,952.90
|
| Rate for Payer: Medicaid All Medicaid |
$3,018.52
|
| Rate for Payer: Medicare All Medicare |
$2,296.70
|
| Rate for Payer: Monida Allegiance |
$3,116.95
|
| Rate for Payer: Monida First Choice Health |
$3,182.57
|
| Rate for Payer: Monida Montana Health Co-op |
$3,116.95
|
| Rate for Payer: Monida PacificSource |
$3,116.95
|
|
|
MR ORBIT FACE NECK W WO CONTRAST
|
Facility
|
OP
|
$3,281.00
|
|
|
Service Code
|
HCPCS 70543 TC
|
| Hospital Charge Code |
5300112
|
|
Hospital Revenue Code
|
614
|
| Min. Negotiated Rate |
$2,296.70 |
| Max. Negotiated Rate |
$3,281.00 |
| Rate for Payer: Aetna Commercial |
$3,116.95
|
| Rate for Payer: Aetna Medicare |
$2,952.90
|
| Rate for Payer: BCBS MT CHIP |
$2,952.90
|
| Rate for Payer: BCBS MT Closed Plan Network |
$3,116.95
|
| Rate for Payer: BCBS MT HealthLink |
$2,952.90
|
| Rate for Payer: BCBS MT Medicare |
$2,952.90
|
| Rate for Payer: BCBS MT POS |
$3,116.95
|
| Rate for Payer: BCBS MT Traditional |
$3,281.00
|
| Rate for Payer: Cash Price |
$2,952.90
|
| Rate for Payer: Cigna Commercial |
$3,116.95
|
| Rate for Payer: Cigna Medicare |
$2,952.90
|
| Rate for Payer: Medicaid All Medicaid |
$3,018.52
|
| Rate for Payer: Medicare All Medicare |
$2,296.70
|
| Rate for Payer: Monida Allegiance |
$3,116.95
|
| Rate for Payer: Monida First Choice Health |
$3,182.57
|
| Rate for Payer: Monida Montana Health Co-op |
$3,116.95
|
| Rate for Payer: Monida PacificSource |
$3,116.95
|
|
|
MR PELVIS W CONTRAST
|
Facility
|
OP
|
$2,544.00
|
|
|
Service Code
|
HCPCS 72196 TC
|
| Hospital Charge Code |
5300114
|
|
Hospital Revenue Code
|
614
|
| Min. Negotiated Rate |
$1,780.80 |
| Max. Negotiated Rate |
$2,544.00 |
| Rate for Payer: Aetna Commercial |
$2,416.80
|
| Rate for Payer: Aetna Medicare |
$2,289.60
|
| Rate for Payer: BCBS MT CHIP |
$2,289.60
|
| Rate for Payer: BCBS MT Closed Plan Network |
$2,416.80
|
| Rate for Payer: BCBS MT HealthLink |
$2,289.60
|
| Rate for Payer: BCBS MT Medicare |
$2,289.60
|
| Rate for Payer: BCBS MT POS |
$2,416.80
|
| Rate for Payer: BCBS MT Traditional |
$2,544.00
|
| Rate for Payer: Cash Price |
$2,289.60
|
| Rate for Payer: Cigna Commercial |
$2,416.80
|
| Rate for Payer: Cigna Medicare |
$2,289.60
|
| Rate for Payer: Medicaid All Medicaid |
$2,340.48
|
| Rate for Payer: Medicare All Medicare |
$1,780.80
|
| Rate for Payer: Monida Allegiance |
$2,416.80
|
| Rate for Payer: Monida First Choice Health |
$2,467.68
|
| Rate for Payer: Monida Montana Health Co-op |
$2,416.80
|
| Rate for Payer: Monida PacificSource |
$2,416.80
|
|
|
MR PELVIS W CONTRAST
|
Facility
|
IP
|
$2,544.00
|
|
|
Service Code
|
HCPCS 72196 TC
|
| Hospital Charge Code |
5300114
|
|
Hospital Revenue Code
|
614
|
| Min. Negotiated Rate |
$1,780.80 |
| Max. Negotiated Rate |
$2,544.00 |
| Rate for Payer: Aetna Commercial |
$2,416.80
|
| Rate for Payer: Aetna Medicare |
$2,289.60
|
| Rate for Payer: BCBS MT CHIP |
$2,289.60
|
| Rate for Payer: BCBS MT Closed Plan Network |
$2,416.80
|
| Rate for Payer: BCBS MT HealthLink |
$2,289.60
|
| Rate for Payer: BCBS MT Medicare |
$2,289.60
|
| Rate for Payer: BCBS MT POS |
$2,416.80
|
| Rate for Payer: BCBS MT Traditional |
$2,544.00
|
| Rate for Payer: Cash Price |
$2,289.60
|
| Rate for Payer: Cigna Commercial |
$2,416.80
|
| Rate for Payer: Cigna Medicare |
$2,289.60
|
| Rate for Payer: Medicaid All Medicaid |
$2,340.48
|
| Rate for Payer: Medicare All Medicare |
$1,780.80
|
| Rate for Payer: Monida Allegiance |
$2,416.80
|
| Rate for Payer: Monida First Choice Health |
$2,467.68
|
| Rate for Payer: Monida Montana Health Co-op |
$2,416.80
|
| Rate for Payer: Monida PacificSource |
$2,416.80
|
|
|
MR PELVIS WO CONTRAST
|
Facility
|
IP
|
$2,288.00
|
|
|
Service Code
|
HCPCS 72195 TC
|
| Hospital Charge Code |
5300115
|
|
Hospital Revenue Code
|
614
|
| Min. Negotiated Rate |
$1,601.60 |
| Max. Negotiated Rate |
$2,288.00 |
| Rate for Payer: Aetna Commercial |
$2,173.60
|
| Rate for Payer: Aetna Medicare |
$2,059.20
|
| Rate for Payer: BCBS MT CHIP |
$2,059.20
|
| Rate for Payer: BCBS MT Closed Plan Network |
$2,173.60
|
| Rate for Payer: BCBS MT HealthLink |
$2,059.20
|
| Rate for Payer: BCBS MT Medicare |
$2,059.20
|
| Rate for Payer: BCBS MT POS |
$2,173.60
|
| Rate for Payer: BCBS MT Traditional |
$2,288.00
|
| Rate for Payer: Cash Price |
$2,059.20
|
| Rate for Payer: Cigna Commercial |
$2,173.60
|
| Rate for Payer: Cigna Medicare |
$2,059.20
|
| Rate for Payer: Medicaid All Medicaid |
$2,104.96
|
| Rate for Payer: Medicare All Medicare |
$1,601.60
|
| Rate for Payer: Monida Allegiance |
$2,173.60
|
| Rate for Payer: Monida First Choice Health |
$2,219.36
|
| Rate for Payer: Monida Montana Health Co-op |
$2,173.60
|
| Rate for Payer: Monida PacificSource |
$2,173.60
|
|
|
MR PELVIS WO CONTRAST
|
Facility
|
OP
|
$2,288.00
|
|
|
Service Code
|
HCPCS 72195 TC
|
| Hospital Charge Code |
5300115
|
|
Hospital Revenue Code
|
614
|
| Min. Negotiated Rate |
$1,601.60 |
| Max. Negotiated Rate |
$2,288.00 |
| Rate for Payer: Aetna Commercial |
$2,173.60
|
| Rate for Payer: Aetna Medicare |
$2,059.20
|
| Rate for Payer: BCBS MT CHIP |
$2,059.20
|
| Rate for Payer: BCBS MT Closed Plan Network |
$2,173.60
|
| Rate for Payer: BCBS MT HealthLink |
$2,059.20
|
| Rate for Payer: BCBS MT Medicare |
$2,059.20
|
| Rate for Payer: BCBS MT POS |
$2,173.60
|
| Rate for Payer: BCBS MT Traditional |
$2,288.00
|
| Rate for Payer: Cash Price |
$2,059.20
|
| Rate for Payer: Cigna Commercial |
$2,173.60
|
| Rate for Payer: Cigna Medicare |
$2,059.20
|
| Rate for Payer: Medicaid All Medicaid |
$2,104.96
|
| Rate for Payer: Medicare All Medicare |
$1,601.60
|
| Rate for Payer: Monida Allegiance |
$2,173.60
|
| Rate for Payer: Monida First Choice Health |
$2,219.36
|
| Rate for Payer: Monida Montana Health Co-op |
$2,173.60
|
| Rate for Payer: Monida PacificSource |
$2,173.60
|
|
|
MR PELVIS W WO CONTRAST
|
Facility
|
OP
|
$3,232.00
|
|
|
Service Code
|
HCPCS 72197 TC
|
| Hospital Charge Code |
5300116
|
|
Hospital Revenue Code
|
614
|
| Min. Negotiated Rate |
$2,262.40 |
| Max. Negotiated Rate |
$3,232.00 |
| Rate for Payer: Aetna Commercial |
$3,070.40
|
| Rate for Payer: Aetna Medicare |
$2,908.80
|
| Rate for Payer: BCBS MT CHIP |
$2,908.80
|
| Rate for Payer: BCBS MT Closed Plan Network |
$3,070.40
|
| Rate for Payer: BCBS MT HealthLink |
$2,908.80
|
| Rate for Payer: BCBS MT Medicare |
$2,908.80
|
| Rate for Payer: BCBS MT POS |
$3,070.40
|
| Rate for Payer: BCBS MT Traditional |
$3,232.00
|
| Rate for Payer: Cash Price |
$2,908.80
|
| Rate for Payer: Cigna Commercial |
$3,070.40
|
| Rate for Payer: Cigna Medicare |
$2,908.80
|
| Rate for Payer: Medicaid All Medicaid |
$2,973.44
|
| Rate for Payer: Medicare All Medicare |
$2,262.40
|
| Rate for Payer: Monida Allegiance |
$3,070.40
|
| Rate for Payer: Monida First Choice Health |
$3,135.04
|
| Rate for Payer: Monida Montana Health Co-op |
$3,070.40
|
| Rate for Payer: Monida PacificSource |
$3,070.40
|
|
|
MR PELVIS W WO CONTRAST
|
Facility
|
IP
|
$3,232.00
|
|
|
Service Code
|
HCPCS 72197 TC
|
| Hospital Charge Code |
5300116
|
|
Hospital Revenue Code
|
614
|
| Min. Negotiated Rate |
$2,262.40 |
| Max. Negotiated Rate |
$3,232.00 |
| Rate for Payer: Aetna Commercial |
$3,070.40
|
| Rate for Payer: Aetna Medicare |
$2,908.80
|
| Rate for Payer: BCBS MT CHIP |
$2,908.80
|
| Rate for Payer: BCBS MT Closed Plan Network |
$3,070.40
|
| Rate for Payer: BCBS MT HealthLink |
$2,908.80
|
| Rate for Payer: BCBS MT Medicare |
$2,908.80
|
| Rate for Payer: BCBS MT POS |
$3,070.40
|
| Rate for Payer: BCBS MT Traditional |
$3,232.00
|
| Rate for Payer: Cash Price |
$2,908.80
|
| Rate for Payer: Cigna Commercial |
$3,070.40
|
| Rate for Payer: Cigna Medicare |
$2,908.80
|
| Rate for Payer: Medicaid All Medicaid |
$2,973.44
|
| Rate for Payer: Medicare All Medicare |
$2,262.40
|
| Rate for Payer: Monida Allegiance |
$3,070.40
|
| Rate for Payer: Monida First Choice Health |
$3,135.04
|
| Rate for Payer: Monida Montana Health Co-op |
$3,070.40
|
| Rate for Payer: Monida PacificSource |
$3,070.40
|
|
|
MRSA/MSSA NAAT
|
Facility
|
IP
|
$184.00
|
|
|
Service Code
|
HCPCS 87641
|
| Hospital Charge Code |
4087882
|
|
Hospital Revenue Code
|
300
|
| 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
|
|
|
MRSA/MSSA NAAT
|
Facility
|
OP
|
$184.00
|
|
|
Service Code
|
HCPCS 87641
|
| Hospital Charge Code |
4087882
|
|
Hospital Revenue Code
|
300
|
| 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
|
|
|
MRSA, NAA SEND OUT(182956)
|
Facility
|
OP
|
$184.00
|
|
|
Service Code
|
HCPCS 87641
|
| Hospital Charge Code |
4087641
|
|
Hospital Revenue Code
|
300
|
| 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
|
|
|
MRSA, NAA SEND OUT(182956)
|
Facility
|
IP
|
$184.00
|
|
|
Service Code
|
HCPCS 87641
|
| Hospital Charge Code |
4087641
|
|
Hospital Revenue Code
|
300
|
| 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
|
|
