|
OP IJ RFA RFA PERPH NV/SUPSCAP 64640
|
Facility
IP
|
$1,550.00
|
|
|
Service Code
|
CPT 64640
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,085.00 |
| Max. Negotiated Rate |
$1,550.00 |
| Rate for Payer: AETNA Commercial |
$1,472.50
|
| Rate for Payer: AETNA Medicare |
$1,395.00
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$1,472.50
|
| Rate for Payer: BCBS Healthlink |
$1,395.00
|
| Rate for Payer: BCBS HMK CHIP |
$1,395.00
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$1,395.00
|
| Rate for Payer: BCBS POS |
$1,472.50
|
| Rate for Payer: BCBS Traditional |
$1,550.00
|
| Rate for Payer: CASH_PRICE |
$1,240.00
|
| Rate for Payer: CIGNA Commercial |
$1,472.50
|
| Rate for Payer: CIGNA Medicare |
$1,395.00
|
| Rate for Payer: HUMANA Commercial |
$1,395.00
|
| Rate for Payer: MEDICAID Medicaid |
$1,426.00
|
| Rate for Payer: MEDICARE Medicare |
$1,085.00
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$1,472.50
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$1,503.50
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$1,472.50
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$1,472.50
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$1,317.50
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$1,240.00
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$1,240.00
|
|
|
OP INJ ANE AGEN AXILLARY NERVE
|
Facility
OP
|
$1,668.00
|
|
|
Service Code
|
CPT 64417
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,167.60 |
| Max. Negotiated Rate |
$1,668.00 |
| Rate for Payer: AETNA Commercial |
$1,584.60
|
| Rate for Payer: AETNA Medicare |
$1,501.20
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$1,584.60
|
| Rate for Payer: BCBS Healthlink |
$1,501.20
|
| Rate for Payer: BCBS HMK CHIP |
$1,501.20
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$1,501.20
|
| Rate for Payer: BCBS POS |
$1,584.60
|
| Rate for Payer: BCBS Traditional |
$1,668.00
|
| Rate for Payer: CASH_PRICE |
$1,334.40
|
| Rate for Payer: CIGNA Commercial |
$1,584.60
|
| Rate for Payer: CIGNA Medicare |
$1,501.20
|
| Rate for Payer: HUMANA Commercial |
$1,501.20
|
| Rate for Payer: MEDICAID Medicaid |
$1,534.56
|
| Rate for Payer: MEDICARE Medicare |
$1,167.60
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$1,584.60
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$1,617.96
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$1,584.60
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$1,584.60
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$1,417.80
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$1,334.40
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$1,334.40
|
|
|
OP INJ ANE AGEN AXILLARY NERVE
|
Facility
IP
|
$1,668.00
|
|
|
Service Code
|
CPT 64417
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,167.60 |
| Max. Negotiated Rate |
$1,668.00 |
| Rate for Payer: AETNA Commercial |
$1,584.60
|
| Rate for Payer: AETNA Medicare |
$1,501.20
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$1,584.60
|
| Rate for Payer: BCBS Healthlink |
$1,501.20
|
| Rate for Payer: BCBS HMK CHIP |
$1,501.20
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$1,501.20
|
| Rate for Payer: BCBS POS |
$1,584.60
|
| Rate for Payer: BCBS Traditional |
$1,668.00
|
| Rate for Payer: CASH_PRICE |
$1,334.40
|
| Rate for Payer: CIGNA Commercial |
$1,584.60
|
| Rate for Payer: CIGNA Medicare |
$1,501.20
|
| Rate for Payer: HUMANA Commercial |
$1,501.20
|
| Rate for Payer: MEDICAID Medicaid |
$1,534.56
|
| Rate for Payer: MEDICARE Medicare |
$1,167.60
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$1,584.60
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$1,617.96
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$1,584.60
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$1,584.60
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$1,417.80
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$1,334.40
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$1,334.40
|
|
|
OP INJ BRACHIAL PLEXUS W/IMAGING 64415
|
Facility
OP
|
$631.00
|
|
|
Service Code
|
CPT 64415
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$441.70 |
| Max. Negotiated Rate |
$631.00 |
| Rate for Payer: AETNA Commercial |
$599.45
|
| Rate for Payer: AETNA Medicare |
$567.90
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$599.45
|
| Rate for Payer: BCBS Healthlink |
$567.90
|
| Rate for Payer: BCBS HMK CHIP |
$567.90
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$567.90
|
| Rate for Payer: BCBS POS |
$599.45
|
| Rate for Payer: BCBS Traditional |
$631.00
|
| Rate for Payer: CASH_PRICE |
$504.80
|
| Rate for Payer: CIGNA Commercial |
$599.45
|
| Rate for Payer: CIGNA Medicare |
$567.90
|
| Rate for Payer: HUMANA Commercial |
$567.90
|
| Rate for Payer: MEDICAID Medicaid |
$580.52
|
| Rate for Payer: MEDICARE Medicare |
$441.70
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$599.45
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$612.07
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$599.45
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$599.45
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$536.35
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$504.80
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$504.80
|
|
|
OP INJ BRACHIAL PLEXUS W/IMAGING 64415
|
Facility
IP
|
$631.00
|
|
|
Service Code
|
CPT 64415
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$441.70 |
| Max. Negotiated Rate |
$631.00 |
| Rate for Payer: AETNA Commercial |
$599.45
|
| Rate for Payer: AETNA Medicare |
$567.90
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$599.45
|
| Rate for Payer: BCBS Healthlink |
$567.90
|
| Rate for Payer: BCBS HMK CHIP |
$567.90
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$567.90
|
| Rate for Payer: BCBS POS |
$599.45
|
| Rate for Payer: BCBS Traditional |
$631.00
|
| Rate for Payer: CASH_PRICE |
$504.80
|
| Rate for Payer: CIGNA Commercial |
$599.45
|
| Rate for Payer: CIGNA Medicare |
$567.90
|
| Rate for Payer: HUMANA Commercial |
$567.90
|
| Rate for Payer: MEDICAID Medicaid |
$580.52
|
| Rate for Payer: MEDICARE Medicare |
$441.70
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$599.45
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$612.07
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$599.45
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$599.45
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$536.35
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$504.80
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$504.80
|
|
|
OP INJ CELIAC PLEX BLOCK 64530
|
Facility
OP
|
$1,734.00
|
|
|
Service Code
|
CPT 64530
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,213.80 |
| Max. Negotiated Rate |
$1,734.00 |
| Rate for Payer: AETNA Commercial |
$1,647.30
|
| Rate for Payer: AETNA Medicare |
$1,560.60
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$1,647.30
|
| Rate for Payer: BCBS Healthlink |
$1,560.60
|
| Rate for Payer: BCBS HMK CHIP |
$1,560.60
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$1,560.60
|
| Rate for Payer: BCBS POS |
$1,647.30
|
| Rate for Payer: BCBS Traditional |
$1,734.00
|
| Rate for Payer: CASH_PRICE |
$1,387.20
|
| Rate for Payer: CIGNA Commercial |
$1,647.30
|
| Rate for Payer: CIGNA Medicare |
$1,560.60
|
| Rate for Payer: HUMANA Commercial |
$1,560.60
|
| Rate for Payer: MEDICAID Medicaid |
$1,595.28
|
| Rate for Payer: MEDICARE Medicare |
$1,213.80
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$1,647.30
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$1,681.98
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$1,647.30
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$1,647.30
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$1,473.90
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$1,387.20
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$1,387.20
|
|
|
OP INJ CELIAC PLEX BLOCK 64530
|
Facility
IP
|
$1,734.00
|
|
|
Service Code
|
CPT 64530
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,213.80 |
| Max. Negotiated Rate |
$1,734.00 |
| Rate for Payer: AETNA Commercial |
$1,647.30
|
| Rate for Payer: AETNA Medicare |
$1,560.60
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$1,647.30
|
| Rate for Payer: BCBS Healthlink |
$1,560.60
|
| Rate for Payer: BCBS HMK CHIP |
$1,560.60
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$1,560.60
|
| Rate for Payer: BCBS POS |
$1,647.30
|
| Rate for Payer: BCBS Traditional |
$1,734.00
|
| Rate for Payer: CASH_PRICE |
$1,387.20
|
| Rate for Payer: CIGNA Commercial |
$1,647.30
|
| Rate for Payer: CIGNA Medicare |
$1,560.60
|
| Rate for Payer: HUMANA Commercial |
$1,560.60
|
| Rate for Payer: MEDICAID Medicaid |
$1,595.28
|
| Rate for Payer: MEDICARE Medicare |
$1,213.80
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$1,647.30
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$1,681.98
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$1,647.30
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$1,647.30
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$1,473.90
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$1,387.20
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$1,387.20
|
|
|
OP INJ DEST FAC NER MIGRN TRT 64615
|
Facility
IP
|
$548.00
|
|
|
Service Code
|
CPT 64615
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$383.60 |
| Max. Negotiated Rate |
$548.00 |
| Rate for Payer: AETNA Commercial |
$520.60
|
| Rate for Payer: AETNA Medicare |
$493.20
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$520.60
|
| Rate for Payer: BCBS Healthlink |
$493.20
|
| Rate for Payer: BCBS HMK CHIP |
$493.20
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$493.20
|
| Rate for Payer: BCBS POS |
$520.60
|
| Rate for Payer: BCBS Traditional |
$548.00
|
| Rate for Payer: CASH_PRICE |
$438.40
|
| Rate for Payer: CIGNA Commercial |
$520.60
|
| Rate for Payer: CIGNA Medicare |
$493.20
|
| Rate for Payer: HUMANA Commercial |
$493.20
|
| Rate for Payer: MEDICAID Medicaid |
$504.16
|
| Rate for Payer: MEDICARE Medicare |
$383.60
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$520.60
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$531.56
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$520.60
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$520.60
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$465.80
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$438.40
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$438.40
|
|
|
OP INJ DEST FAC NER MIGRN TRT 64615
|
Facility
OP
|
$548.00
|
|
|
Service Code
|
CPT 64615
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$383.60 |
| Max. Negotiated Rate |
$548.00 |
| Rate for Payer: AETNA Commercial |
$520.60
|
| Rate for Payer: AETNA Medicare |
$493.20
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$520.60
|
| Rate for Payer: BCBS Healthlink |
$493.20
|
| Rate for Payer: BCBS HMK CHIP |
$493.20
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$493.20
|
| Rate for Payer: BCBS POS |
$520.60
|
| Rate for Payer: BCBS Traditional |
$548.00
|
| Rate for Payer: CASH_PRICE |
$438.40
|
| Rate for Payer: CIGNA Commercial |
$520.60
|
| Rate for Payer: CIGNA Medicare |
$493.20
|
| Rate for Payer: HUMANA Commercial |
$493.20
|
| Rate for Payer: MEDICAID Medicaid |
$504.16
|
| Rate for Payer: MEDICARE Medicare |
$383.60
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$520.60
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$531.56
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$520.60
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$520.60
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$465.80
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$438.40
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$438.40
|
|
|
OP INJ DESTR NERO AGT, PLANTAR NV 64632
|
Facility
IP
|
$254.00
|
|
|
Service Code
|
CPT 64632
|
| Hospital Charge Code |
20230701
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$177.80 |
| Max. Negotiated Rate |
$254.00 |
| Rate for Payer: AETNA Commercial |
$241.30
|
| Rate for Payer: AETNA Medicare |
$228.60
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$241.30
|
| Rate for Payer: BCBS Healthlink |
$228.60
|
| Rate for Payer: BCBS HMK CHIP |
$228.60
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$228.60
|
| Rate for Payer: BCBS POS |
$241.30
|
| Rate for Payer: BCBS Traditional |
$254.00
|
| Rate for Payer: CASH_PRICE |
$203.20
|
| Rate for Payer: CIGNA Commercial |
$241.30
|
| Rate for Payer: CIGNA Medicare |
$228.60
|
| Rate for Payer: HUMANA Commercial |
$228.60
|
| Rate for Payer: MEDICAID Medicaid |
$233.68
|
| Rate for Payer: MEDICARE Medicare |
$177.80
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$241.30
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$246.38
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$241.30
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$241.30
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$215.90
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$203.20
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$203.20
|
|
|
OP INJ DESTR NERO AGT, PLANTAR NV 64632
|
Facility
OP
|
$254.00
|
|
|
Service Code
|
CPT 64632
|
| Hospital Charge Code |
20230701
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$177.80 |
| Max. Negotiated Rate |
$254.00 |
| Rate for Payer: AETNA Commercial |
$241.30
|
| Rate for Payer: AETNA Medicare |
$228.60
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$241.30
|
| Rate for Payer: BCBS Healthlink |
$228.60
|
| Rate for Payer: BCBS HMK CHIP |
$228.60
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$228.60
|
| Rate for Payer: BCBS POS |
$241.30
|
| Rate for Payer: BCBS Traditional |
$254.00
|
| Rate for Payer: CASH_PRICE |
$203.20
|
| Rate for Payer: CIGNA Commercial |
$241.30
|
| Rate for Payer: CIGNA Medicare |
$228.60
|
| Rate for Payer: HUMANA Commercial |
$228.60
|
| Rate for Payer: MEDICAID Medicaid |
$233.68
|
| Rate for Payer: MEDICARE Medicare |
$177.80
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$241.30
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$246.38
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$241.30
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$241.30
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$215.90
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$203.20
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$203.20
|
|
|
OP INJ DESTR NERO AGT, PUDENDAL NV 64630
|
Facility
OP
|
$1,662.00
|
|
|
Service Code
|
CPT 64630
|
| Hospital Charge Code |
20230701
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,163.40 |
| Max. Negotiated Rate |
$1,662.00 |
| Rate for Payer: AETNA Commercial |
$1,578.90
|
| Rate for Payer: AETNA Medicare |
$1,495.80
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$1,578.90
|
| Rate for Payer: BCBS Healthlink |
$1,495.80
|
| Rate for Payer: BCBS HMK CHIP |
$1,495.80
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$1,495.80
|
| Rate for Payer: BCBS POS |
$1,578.90
|
| Rate for Payer: BCBS Traditional |
$1,662.00
|
| Rate for Payer: CASH_PRICE |
$1,329.60
|
| Rate for Payer: CIGNA Commercial |
$1,578.90
|
| Rate for Payer: CIGNA Medicare |
$1,495.80
|
| Rate for Payer: HUMANA Commercial |
$1,495.80
|
| Rate for Payer: MEDICAID Medicaid |
$1,529.04
|
| Rate for Payer: MEDICARE Medicare |
$1,163.40
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$1,578.90
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$1,612.14
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$1,578.90
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$1,578.90
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$1,412.70
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$1,329.60
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$1,329.60
|
|
|
OP INJ DESTR NERO AGT, PUDENDAL NV 64630
|
Facility
IP
|
$1,662.00
|
|
|
Service Code
|
CPT 64630
|
| Hospital Charge Code |
20230701
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,163.40 |
| Max. Negotiated Rate |
$1,662.00 |
| Rate for Payer: AETNA Commercial |
$1,578.90
|
| Rate for Payer: AETNA Medicare |
$1,495.80
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$1,578.90
|
| Rate for Payer: BCBS Healthlink |
$1,495.80
|
| Rate for Payer: BCBS HMK CHIP |
$1,495.80
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$1,495.80
|
| Rate for Payer: BCBS POS |
$1,578.90
|
| Rate for Payer: BCBS Traditional |
$1,662.00
|
| Rate for Payer: CASH_PRICE |
$1,329.60
|
| Rate for Payer: CIGNA Commercial |
$1,578.90
|
| Rate for Payer: CIGNA Medicare |
$1,495.80
|
| Rate for Payer: HUMANA Commercial |
$1,495.80
|
| Rate for Payer: MEDICAID Medicaid |
$1,529.04
|
| Rate for Payer: MEDICARE Medicare |
$1,163.40
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$1,578.90
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$1,612.14
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$1,578.90
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$1,578.90
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$1,412.70
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$1,329.60
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$1,329.60
|
|
|
OP INJ DESTRUCTION OF FACIAL NERVE 64612
|
Facility
OP
|
$595.00
|
|
|
Service Code
|
CPT 64612
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
760
|
| Min. Negotiated Rate |
$416.50 |
| Max. Negotiated Rate |
$595.00 |
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$565.25
|
| Rate for Payer: AETNA Commercial |
$565.25
|
| Rate for Payer: AETNA Medicare |
$535.50
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$565.25
|
| Rate for Payer: BCBS Healthlink |
$535.50
|
| Rate for Payer: BCBS HMK CHIP |
$535.50
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$535.50
|
| Rate for Payer: BCBS POS |
$565.25
|
| Rate for Payer: BCBS Traditional |
$595.00
|
| Rate for Payer: CASH_PRICE |
$476.00
|
| Rate for Payer: CIGNA Commercial |
$565.25
|
| Rate for Payer: CIGNA Medicare |
$535.50
|
| Rate for Payer: HUMANA Commercial |
$535.50
|
| Rate for Payer: MEDICAID Medicaid |
$547.40
|
| Rate for Payer: MEDICARE Medicare |
$416.50
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$577.15
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$565.25
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$565.25
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$505.75
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$476.00
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$476.00
|
|
|
OP INJ DESTRUCTION OF FACIAL NERVE 64612
|
Facility
IP
|
$595.00
|
|
|
Service Code
|
CPT 64612
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
760
|
| Min. Negotiated Rate |
$416.50 |
| Max. Negotiated Rate |
$595.00 |
| Rate for Payer: AETNA Commercial |
$565.25
|
| Rate for Payer: AETNA Medicare |
$535.50
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$565.25
|
| Rate for Payer: BCBS Healthlink |
$535.50
|
| Rate for Payer: BCBS HMK CHIP |
$535.50
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$535.50
|
| Rate for Payer: BCBS POS |
$565.25
|
| Rate for Payer: BCBS Traditional |
$595.00
|
| Rate for Payer: CASH_PRICE |
$476.00
|
| Rate for Payer: CIGNA Commercial |
$565.25
|
| Rate for Payer: CIGNA Medicare |
$535.50
|
| Rate for Payer: HUMANA Commercial |
$535.50
|
| Rate for Payer: MEDICAID Medicaid |
$547.40
|
| Rate for Payer: MEDICARE Medicare |
$416.50
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$565.25
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$577.15
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$565.25
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$565.25
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$505.75
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$476.00
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$476.00
|
|
|
OP INJ FACET JNT C/T 1L W/IMA 64490
|
Facility
IP
|
$1,498.00
|
|
|
Service Code
|
CPT 64490
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,048.60 |
| Max. Negotiated Rate |
$1,498.00 |
| Rate for Payer: AETNA Commercial |
$1,423.10
|
| Rate for Payer: AETNA Medicare |
$1,348.20
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$1,423.10
|
| Rate for Payer: BCBS Healthlink |
$1,348.20
|
| Rate for Payer: BCBS HMK CHIP |
$1,348.20
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$1,348.20
|
| Rate for Payer: BCBS POS |
$1,423.10
|
| Rate for Payer: BCBS Traditional |
$1,498.00
|
| Rate for Payer: CASH_PRICE |
$1,198.40
|
| Rate for Payer: CIGNA Commercial |
$1,423.10
|
| Rate for Payer: CIGNA Medicare |
$1,348.20
|
| Rate for Payer: HUMANA Commercial |
$1,348.20
|
| Rate for Payer: MEDICAID Medicaid |
$1,378.16
|
| Rate for Payer: MEDICARE Medicare |
$1,048.60
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$1,423.10
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$1,453.06
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$1,423.10
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$1,423.10
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$1,273.30
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$1,198.40
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$1,198.40
|
|
|
OP INJ FACET JNT C/T 1L W/IMA 64490
|
Facility
OP
|
$1,498.00
|
|
|
Service Code
|
CPT 64490
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,048.60 |
| Max. Negotiated Rate |
$1,498.00 |
| Rate for Payer: AETNA Commercial |
$1,423.10
|
| Rate for Payer: AETNA Medicare |
$1,348.20
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$1,423.10
|
| Rate for Payer: BCBS Healthlink |
$1,348.20
|
| Rate for Payer: BCBS HMK CHIP |
$1,348.20
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$1,348.20
|
| Rate for Payer: BCBS POS |
$1,423.10
|
| Rate for Payer: BCBS Traditional |
$1,498.00
|
| Rate for Payer: CASH_PRICE |
$1,198.40
|
| Rate for Payer: CIGNA Commercial |
$1,423.10
|
| Rate for Payer: CIGNA Medicare |
$1,348.20
|
| Rate for Payer: HUMANA Commercial |
$1,348.20
|
| Rate for Payer: MEDICAID Medicaid |
$1,378.16
|
| Rate for Payer: MEDICARE Medicare |
$1,048.60
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$1,423.10
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$1,453.06
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$1,423.10
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$1,423.10
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$1,273.30
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$1,198.40
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$1,198.40
|
|
|
OP INJ FACET JNT C/T 2ND LEVEL 64491
|
Facility
OP
|
$755.00
|
|
|
Service Code
|
CPT 64491
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$528.50 |
| Max. Negotiated Rate |
$755.00 |
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$717.25
|
| Rate for Payer: AETNA Commercial |
$717.25
|
| Rate for Payer: AETNA Medicare |
$679.50
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$717.25
|
| Rate for Payer: BCBS Healthlink |
$679.50
|
| Rate for Payer: BCBS HMK CHIP |
$679.50
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$679.50
|
| Rate for Payer: BCBS POS |
$717.25
|
| Rate for Payer: BCBS Traditional |
$755.00
|
| Rate for Payer: CASH_PRICE |
$604.00
|
| Rate for Payer: CIGNA Commercial |
$717.25
|
| Rate for Payer: CIGNA Medicare |
$679.50
|
| Rate for Payer: HUMANA Commercial |
$679.50
|
| Rate for Payer: MEDICAID Medicaid |
$694.60
|
| Rate for Payer: MEDICARE Medicare |
$528.50
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$732.35
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$717.25
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$717.25
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$641.75
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$604.00
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$604.00
|
|
|
OP INJ FACET JNT C/T 2ND LEVEL 64491
|
Facility
IP
|
$755.00
|
|
|
Service Code
|
CPT 64491
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$528.50 |
| Max. Negotiated Rate |
$755.00 |
| Rate for Payer: AETNA Commercial |
$717.25
|
| Rate for Payer: AETNA Medicare |
$679.50
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$717.25
|
| Rate for Payer: BCBS Healthlink |
$679.50
|
| Rate for Payer: BCBS HMK CHIP |
$679.50
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$679.50
|
| Rate for Payer: BCBS POS |
$717.25
|
| Rate for Payer: BCBS Traditional |
$755.00
|
| Rate for Payer: CASH_PRICE |
$604.00
|
| Rate for Payer: CIGNA Commercial |
$717.25
|
| Rate for Payer: CIGNA Medicare |
$679.50
|
| Rate for Payer: HUMANA Commercial |
$679.50
|
| Rate for Payer: MEDICAID Medicaid |
$694.60
|
| Rate for Payer: MEDICARE Medicare |
$528.50
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$717.25
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$732.35
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$717.25
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$717.25
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$641.75
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$604.00
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$604.00
|
|
|
OP INJ FACET JNT C/T 3RDL WIM 64492
|
Facility
OP
|
$727.00
|
|
|
Service Code
|
CPT 64492
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$508.90 |
| Max. Negotiated Rate |
$727.00 |
| Rate for Payer: AETNA Commercial |
$690.65
|
| Rate for Payer: AETNA Medicare |
$654.30
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$690.65
|
| Rate for Payer: BCBS Healthlink |
$654.30
|
| Rate for Payer: BCBS HMK CHIP |
$654.30
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$654.30
|
| Rate for Payer: BCBS POS |
$690.65
|
| Rate for Payer: BCBS Traditional |
$727.00
|
| Rate for Payer: CASH_PRICE |
$581.60
|
| Rate for Payer: CIGNA Commercial |
$690.65
|
| Rate for Payer: CIGNA Medicare |
$654.30
|
| Rate for Payer: HUMANA Commercial |
$654.30
|
| Rate for Payer: MEDICAID Medicaid |
$668.84
|
| Rate for Payer: MEDICARE Medicare |
$508.90
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$690.65
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$705.19
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$690.65
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$690.65
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$617.95
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$581.60
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$581.60
|
|
|
OP INJ FACET JNT C/T 3RDL WIM 64492
|
Facility
IP
|
$727.00
|
|
|
Service Code
|
CPT 64492
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$508.90 |
| Max. Negotiated Rate |
$727.00 |
| Rate for Payer: AETNA Commercial |
$690.65
|
| Rate for Payer: AETNA Medicare |
$654.30
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$690.65
|
| Rate for Payer: BCBS Healthlink |
$654.30
|
| Rate for Payer: BCBS HMK CHIP |
$654.30
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$654.30
|
| Rate for Payer: BCBS POS |
$690.65
|
| Rate for Payer: BCBS Traditional |
$727.00
|
| Rate for Payer: CASH_PRICE |
$581.60
|
| Rate for Payer: CIGNA Commercial |
$690.65
|
| Rate for Payer: CIGNA Medicare |
$654.30
|
| Rate for Payer: HUMANA Commercial |
$654.30
|
| Rate for Payer: MEDICAID Medicaid |
$668.84
|
| Rate for Payer: MEDICARE Medicare |
$508.90
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$690.65
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$705.19
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$690.65
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$690.65
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$617.95
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$581.60
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$581.60
|
|
|
OP INJ FACET JNT L/S 1L 64493
|
Facility
OP
|
$1,524.00
|
|
|
Service Code
|
CPT 64493
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,066.80 |
| Max. Negotiated Rate |
$1,524.00 |
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$1,447.80
|
| Rate for Payer: AETNA Commercial |
$1,447.80
|
| Rate for Payer: AETNA Medicare |
$1,371.60
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$1,447.80
|
| Rate for Payer: BCBS Healthlink |
$1,371.60
|
| Rate for Payer: BCBS HMK CHIP |
$1,371.60
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$1,371.60
|
| Rate for Payer: BCBS POS |
$1,447.80
|
| Rate for Payer: BCBS Traditional |
$1,524.00
|
| Rate for Payer: CASH_PRICE |
$1,219.20
|
| Rate for Payer: CIGNA Commercial |
$1,447.80
|
| Rate for Payer: CIGNA Medicare |
$1,371.60
|
| Rate for Payer: HUMANA Commercial |
$1,371.60
|
| Rate for Payer: MEDICAID Medicaid |
$1,402.08
|
| Rate for Payer: MEDICARE Medicare |
$1,066.80
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$1,478.28
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$1,447.80
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$1,447.80
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$1,295.40
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$1,219.20
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$1,219.20
|
|
|
OP INJ FACET JNT L/S 1L 64493
|
Facility
IP
|
$1,524.00
|
|
|
Service Code
|
CPT 64493
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,066.80 |
| Max. Negotiated Rate |
$1,524.00 |
| Rate for Payer: AETNA Commercial |
$1,447.80
|
| Rate for Payer: AETNA Medicare |
$1,371.60
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$1,447.80
|
| Rate for Payer: BCBS Healthlink |
$1,371.60
|
| Rate for Payer: BCBS HMK CHIP |
$1,371.60
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$1,371.60
|
| Rate for Payer: BCBS POS |
$1,447.80
|
| Rate for Payer: BCBS Traditional |
$1,524.00
|
| Rate for Payer: CASH_PRICE |
$1,219.20
|
| Rate for Payer: CIGNA Commercial |
$1,447.80
|
| Rate for Payer: CIGNA Medicare |
$1,371.60
|
| Rate for Payer: HUMANA Commercial |
$1,371.60
|
| Rate for Payer: MEDICAID Medicaid |
$1,402.08
|
| Rate for Payer: MEDICARE Medicare |
$1,066.80
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$1,447.80
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$1,478.28
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$1,447.80
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$1,447.80
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$1,295.40
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$1,219.20
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$1,219.20
|
|
|
OP INJ FACET JNT L/S 2 L 64494
|
Facility
OP
|
$785.00
|
|
|
Service Code
|
CPT 64494
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$549.50 |
| Max. Negotiated Rate |
$785.00 |
| Rate for Payer: AETNA Commercial |
$745.75
|
| Rate for Payer: AETNA Medicare |
$706.50
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$745.75
|
| Rate for Payer: BCBS Healthlink |
$706.50
|
| Rate for Payer: BCBS HMK CHIP |
$706.50
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$706.50
|
| Rate for Payer: BCBS POS |
$745.75
|
| Rate for Payer: BCBS Traditional |
$785.00
|
| Rate for Payer: CASH_PRICE |
$628.00
|
| Rate for Payer: CIGNA Commercial |
$745.75
|
| Rate for Payer: CIGNA Medicare |
$706.50
|
| Rate for Payer: HUMANA Commercial |
$706.50
|
| Rate for Payer: MEDICAID Medicaid |
$722.20
|
| Rate for Payer: MEDICARE Medicare |
$549.50
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$745.75
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$761.45
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$745.75
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$745.75
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$667.25
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$628.00
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$628.00
|
|
|
OP INJ FACET JNT L/S 2 L 64494
|
Facility
IP
|
$785.00
|
|
|
Service Code
|
CPT 64494
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$549.50 |
| Max. Negotiated Rate |
$785.00 |
| Rate for Payer: AETNA Commercial |
$745.75
|
| Rate for Payer: AETNA Medicare |
$706.50
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$745.75
|
| Rate for Payer: BCBS Healthlink |
$706.50
|
| Rate for Payer: BCBS HMK CHIP |
$706.50
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$706.50
|
| Rate for Payer: BCBS POS |
$745.75
|
| Rate for Payer: BCBS Traditional |
$785.00
|
| Rate for Payer: CASH_PRICE |
$628.00
|
| Rate for Payer: CIGNA Commercial |
$745.75
|
| Rate for Payer: CIGNA Medicare |
$706.50
|
| Rate for Payer: HUMANA Commercial |
$706.50
|
| Rate for Payer: MEDICAID Medicaid |
$722.20
|
| Rate for Payer: MEDICARE Medicare |
$549.50
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$745.75
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$761.45
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$745.75
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$745.75
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$667.25
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$628.00
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$628.00
|
|
