|
OP INJ FACET JNT L/S 3L + 64495
|
Facility
IP
|
$748.00
|
|
|
Service Code
|
CPT 64495
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$523.60 |
| Max. Negotiated Rate |
$748.00 |
| Rate for Payer: AETNA Commercial |
$710.60
|
| Rate for Payer: AETNA Medicare |
$673.20
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$710.60
|
| Rate for Payer: BCBS Healthlink |
$673.20
|
| Rate for Payer: BCBS HMK CHIP |
$673.20
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$673.20
|
| Rate for Payer: BCBS POS |
$710.60
|
| Rate for Payer: BCBS Traditional |
$748.00
|
| Rate for Payer: CASH_PRICE |
$598.40
|
| Rate for Payer: CIGNA Commercial |
$710.60
|
| Rate for Payer: CIGNA Medicare |
$673.20
|
| Rate for Payer: HUMANA Commercial |
$673.20
|
| Rate for Payer: MEDICAID Medicaid |
$688.16
|
| Rate for Payer: MEDICARE Medicare |
$523.60
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$710.60
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$725.56
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$710.60
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$710.60
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$635.80
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$598.40
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$598.40
|
|
|
OP INJ FACET JNT L/S 3L + 64495
|
Facility
OP
|
$748.00
|
|
|
Service Code
|
CPT 64495
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$523.60 |
| Max. Negotiated Rate |
$748.00 |
| Rate for Payer: AETNA Commercial |
$710.60
|
| Rate for Payer: AETNA Medicare |
$673.20
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$710.60
|
| Rate for Payer: BCBS Healthlink |
$673.20
|
| Rate for Payer: BCBS HMK CHIP |
$673.20
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$673.20
|
| Rate for Payer: BCBS POS |
$710.60
|
| Rate for Payer: BCBS Traditional |
$748.00
|
| Rate for Payer: CASH_PRICE |
$598.40
|
| Rate for Payer: CIGNA Commercial |
$710.60
|
| Rate for Payer: CIGNA Medicare |
$673.20
|
| Rate for Payer: HUMANA Commercial |
$673.20
|
| Rate for Payer: MEDICAID Medicaid |
$688.16
|
| Rate for Payer: MEDICARE Medicare |
$523.60
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$710.60
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$725.56
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$710.60
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$710.60
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$635.80
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$598.40
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$598.40
|
|
|
OP INJ FEMORAL NERVE BLOCK 64447
|
Facility
OP
|
$1,892.00
|
|
|
Service Code
|
CPT 64447
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,324.40 |
| Max. Negotiated Rate |
$1,892.00 |
| Rate for Payer: AETNA Commercial |
$1,797.40
|
| Rate for Payer: AETNA Medicare |
$1,702.80
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$1,797.40
|
| Rate for Payer: BCBS Healthlink |
$1,702.80
|
| Rate for Payer: BCBS HMK CHIP |
$1,702.80
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$1,702.80
|
| Rate for Payer: BCBS POS |
$1,797.40
|
| Rate for Payer: BCBS Traditional |
$1,892.00
|
| Rate for Payer: CASH_PRICE |
$1,513.60
|
| Rate for Payer: CIGNA Commercial |
$1,797.40
|
| Rate for Payer: CIGNA Medicare |
$1,702.80
|
| Rate for Payer: HUMANA Commercial |
$1,702.80
|
| Rate for Payer: MEDICAID Medicaid |
$1,740.64
|
| Rate for Payer: MEDICARE Medicare |
$1,324.40
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$1,797.40
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$1,835.24
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$1,797.40
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$1,797.40
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$1,608.20
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$1,513.60
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$1,513.60
|
|
|
OP INJ FEMORAL NERVE BLOCK 64447
|
Facility
IP
|
$1,892.00
|
|
|
Service Code
|
CPT 64447
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,324.40 |
| Max. Negotiated Rate |
$1,892.00 |
| Rate for Payer: AETNA Commercial |
$1,797.40
|
| Rate for Payer: AETNA Medicare |
$1,702.80
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$1,797.40
|
| Rate for Payer: BCBS Healthlink |
$1,702.80
|
| Rate for Payer: BCBS HMK CHIP |
$1,702.80
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$1,702.80
|
| Rate for Payer: BCBS POS |
$1,797.40
|
| Rate for Payer: BCBS Traditional |
$1,892.00
|
| Rate for Payer: CASH_PRICE |
$1,513.60
|
| Rate for Payer: CIGNA Commercial |
$1,797.40
|
| Rate for Payer: CIGNA Medicare |
$1,702.80
|
| Rate for Payer: HUMANA Commercial |
$1,702.80
|
| Rate for Payer: MEDICAID Medicaid |
$1,740.64
|
| Rate for Payer: MEDICARE Medicare |
$1,324.40
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$1,797.40
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$1,835.24
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$1,797.40
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$1,797.40
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$1,608.20
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$1,513.60
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$1,513.60
|
|
|
OP INJ GRTER OCCIPT NERVE BLOCK 64405
|
Facility
IP
|
$631.00
|
|
|
Service Code
|
CPT 64405
|
| 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 GRTER OCCIPT NERVE BLOCK 64405
|
Facility
OP
|
$631.00
|
|
|
Service Code
|
CPT 64405
|
| 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 ILIOING/ILIOHYPOG NV BLOCK 64425
|
Facility
IP
|
$775.00
|
|
|
Service Code
|
CPT 64425
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$542.50 |
| Max. Negotiated Rate |
$775.00 |
| Rate for Payer: AETNA Commercial |
$736.25
|
| Rate for Payer: AETNA Medicare |
$697.50
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$736.25
|
| Rate for Payer: BCBS Healthlink |
$697.50
|
| Rate for Payer: BCBS HMK CHIP |
$697.50
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$697.50
|
| Rate for Payer: BCBS POS |
$736.25
|
| Rate for Payer: BCBS Traditional |
$775.00
|
| Rate for Payer: CASH_PRICE |
$620.00
|
| Rate for Payer: CIGNA Commercial |
$736.25
|
| Rate for Payer: CIGNA Medicare |
$697.50
|
| Rate for Payer: HUMANA Commercial |
$697.50
|
| Rate for Payer: MEDICAID Medicaid |
$713.00
|
| Rate for Payer: MEDICARE Medicare |
$542.50
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$736.25
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$751.75
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$736.25
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$736.25
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$658.75
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$620.00
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$620.00
|
|
|
OP INJ ILIOING/ILIOHYPOG NV BLOCK 64425
|
Facility
OP
|
$775.00
|
|
|
Service Code
|
CPT 64425
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$542.50 |
| Max. Negotiated Rate |
$775.00 |
| Rate for Payer: AETNA Commercial |
$736.25
|
| Rate for Payer: AETNA Medicare |
$697.50
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$736.25
|
| Rate for Payer: BCBS Healthlink |
$697.50
|
| Rate for Payer: BCBS HMK CHIP |
$697.50
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$697.50
|
| Rate for Payer: BCBS POS |
$736.25
|
| Rate for Payer: BCBS Traditional |
$775.00
|
| Rate for Payer: CASH_PRICE |
$620.00
|
| Rate for Payer: CIGNA Commercial |
$736.25
|
| Rate for Payer: CIGNA Medicare |
$697.50
|
| Rate for Payer: HUMANA Commercial |
$697.50
|
| Rate for Payer: MEDICAID Medicaid |
$713.00
|
| Rate for Payer: MEDICARE Medicare |
$542.50
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$736.25
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$751.75
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$736.25
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$736.25
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$658.75
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$620.00
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$620.00
|
|
|
OP INJ INTRCOST NERVE BLOCK SINGLE 64420
|
Facility
OP
|
$800.00
|
|
|
Service Code
|
CPT 64420
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$560.00 |
| Max. Negotiated Rate |
$800.00 |
| Rate for Payer: AETNA Commercial |
$760.00
|
| Rate for Payer: AETNA Medicare |
$720.00
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$760.00
|
| Rate for Payer: BCBS Healthlink |
$720.00
|
| Rate for Payer: BCBS HMK CHIP |
$720.00
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$720.00
|
| Rate for Payer: BCBS POS |
$760.00
|
| Rate for Payer: BCBS Traditional |
$800.00
|
| Rate for Payer: CASH_PRICE |
$640.00
|
| Rate for Payer: CIGNA Commercial |
$760.00
|
| Rate for Payer: CIGNA Medicare |
$720.00
|
| Rate for Payer: HUMANA Commercial |
$720.00
|
| Rate for Payer: MEDICAID Medicaid |
$736.00
|
| Rate for Payer: MEDICARE Medicare |
$560.00
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$760.00
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$776.00
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$760.00
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$760.00
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$680.00
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$640.00
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$640.00
|
|
|
OP INJ INTRCOST NERVE BLOCK SINGLE 64420
|
Facility
IP
|
$800.00
|
|
|
Service Code
|
CPT 64420
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$560.00 |
| Max. Negotiated Rate |
$800.00 |
| Rate for Payer: AETNA Commercial |
$760.00
|
| Rate for Payer: AETNA Medicare |
$720.00
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$760.00
|
| Rate for Payer: BCBS Healthlink |
$720.00
|
| Rate for Payer: BCBS HMK CHIP |
$720.00
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$720.00
|
| Rate for Payer: BCBS POS |
$760.00
|
| Rate for Payer: BCBS Traditional |
$800.00
|
| Rate for Payer: CASH_PRICE |
$640.00
|
| Rate for Payer: CIGNA Commercial |
$760.00
|
| Rate for Payer: CIGNA Medicare |
$720.00
|
| Rate for Payer: HUMANA Commercial |
$720.00
|
| Rate for Payer: MEDICAID Medicaid |
$736.00
|
| Rate for Payer: MEDICARE Medicare |
$560.00
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$760.00
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$776.00
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$760.00
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$760.00
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$680.00
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$640.00
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$640.00
|
|
|
OP INJ INTRLAMIN LUMAB W/IMA 62323
|
Facility
IP
|
$2,216.00
|
|
|
Service Code
|
CPT 62323
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,551.20 |
| Max. Negotiated Rate |
$2,216.00 |
| Rate for Payer: AETNA Commercial |
$2,105.20
|
| Rate for Payer: AETNA Medicare |
$1,994.40
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$2,105.20
|
| Rate for Payer: BCBS Healthlink |
$1,994.40
|
| Rate for Payer: BCBS HMK CHIP |
$1,994.40
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$1,994.40
|
| Rate for Payer: BCBS POS |
$2,105.20
|
| Rate for Payer: BCBS Traditional |
$2,216.00
|
| Rate for Payer: CASH_PRICE |
$1,772.80
|
| Rate for Payer: CIGNA Commercial |
$2,105.20
|
| Rate for Payer: CIGNA Medicare |
$1,994.40
|
| Rate for Payer: HUMANA Commercial |
$1,994.40
|
| Rate for Payer: MEDICAID Medicaid |
$2,038.72
|
| Rate for Payer: MEDICARE Medicare |
$1,551.20
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$2,105.20
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$2,149.52
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$2,105.20
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$2,105.20
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$1,883.60
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$1,772.80
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$1,772.80
|
|
|
OP INJ INTRLAMIN LUMAB W/IMA 62323
|
Facility
OP
|
$2,216.00
|
|
|
Service Code
|
CPT 62323
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,551.20 |
| Max. Negotiated Rate |
$2,216.00 |
| Rate for Payer: AETNA Commercial |
$2,105.20
|
| Rate for Payer: AETNA Medicare |
$1,994.40
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$2,105.20
|
| Rate for Payer: BCBS Healthlink |
$1,994.40
|
| Rate for Payer: BCBS HMK CHIP |
$1,994.40
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$1,994.40
|
| Rate for Payer: BCBS POS |
$2,105.20
|
| Rate for Payer: BCBS Traditional |
$2,216.00
|
| Rate for Payer: CASH_PRICE |
$1,772.80
|
| Rate for Payer: CIGNA Commercial |
$2,105.20
|
| Rate for Payer: CIGNA Medicare |
$1,994.40
|
| Rate for Payer: HUMANA Commercial |
$1,994.40
|
| Rate for Payer: MEDICAID Medicaid |
$2,038.72
|
| Rate for Payer: MEDICARE Medicare |
$1,551.20
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$2,105.20
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$2,149.52
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$2,105.20
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$2,105.20
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$1,883.60
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$1,772.80
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$1,772.80
|
|
|
OP INJ OP INJ TRANFOR C/T ADDTL 64480
|
Facility
IP
|
$894.00
|
|
|
Service Code
|
CPT 64480
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$625.80 |
| Max. Negotiated Rate |
$894.00 |
| Rate for Payer: AETNA Commercial |
$849.30
|
| Rate for Payer: AETNA Medicare |
$804.60
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$849.30
|
| Rate for Payer: BCBS Healthlink |
$804.60
|
| Rate for Payer: BCBS HMK CHIP |
$804.60
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$804.60
|
| Rate for Payer: BCBS POS |
$849.30
|
| Rate for Payer: BCBS Traditional |
$894.00
|
| Rate for Payer: CASH_PRICE |
$715.20
|
| Rate for Payer: CIGNA Commercial |
$849.30
|
| Rate for Payer: CIGNA Medicare |
$804.60
|
| Rate for Payer: HUMANA Commercial |
$804.60
|
| Rate for Payer: MEDICAID Medicaid |
$822.48
|
| Rate for Payer: MEDICARE Medicare |
$625.80
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$849.30
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$867.18
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$849.30
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$849.30
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$759.90
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$715.20
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$715.20
|
|
|
OP INJ OP INJ TRANFOR C/T ADDTL 64480
|
Facility
OP
|
$894.00
|
|
|
Service Code
|
CPT 64480
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$625.80 |
| Max. Negotiated Rate |
$894.00 |
| Rate for Payer: AETNA Commercial |
$849.30
|
| Rate for Payer: AETNA Medicare |
$804.60
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$849.30
|
| Rate for Payer: BCBS Healthlink |
$804.60
|
| Rate for Payer: BCBS HMK CHIP |
$804.60
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$804.60
|
| Rate for Payer: BCBS POS |
$849.30
|
| Rate for Payer: BCBS Traditional |
$894.00
|
| Rate for Payer: CASH_PRICE |
$715.20
|
| Rate for Payer: CIGNA Commercial |
$849.30
|
| Rate for Payer: CIGNA Medicare |
$804.60
|
| Rate for Payer: HUMANA Commercial |
$804.60
|
| Rate for Payer: MEDICAID Medicaid |
$822.48
|
| Rate for Payer: MEDICARE Medicare |
$625.80
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$849.30
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$867.18
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$849.30
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$849.30
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$759.90
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$715.20
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$715.20
|
|
|
OP INJ OP INJ TRANSFORA L/S 1 64483
|
Facility
OP
|
$2,344.00
|
|
|
Service Code
|
CPT 64483
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,640.80 |
| Max. Negotiated Rate |
$2,344.00 |
| Rate for Payer: AETNA Commercial |
$2,226.80
|
| Rate for Payer: AETNA Medicare |
$2,109.60
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$2,226.80
|
| Rate for Payer: BCBS Healthlink |
$2,109.60
|
| Rate for Payer: BCBS HMK CHIP |
$2,109.60
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$2,109.60
|
| Rate for Payer: BCBS POS |
$2,226.80
|
| Rate for Payer: BCBS Traditional |
$2,344.00
|
| Rate for Payer: CASH_PRICE |
$1,875.20
|
| Rate for Payer: CIGNA Commercial |
$2,226.80
|
| Rate for Payer: CIGNA Medicare |
$2,109.60
|
| Rate for Payer: HUMANA Commercial |
$2,109.60
|
| Rate for Payer: MEDICAID Medicaid |
$2,156.48
|
| Rate for Payer: MEDICARE Medicare |
$1,640.80
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$2,226.80
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$2,273.68
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$2,226.80
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$2,226.80
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$1,992.40
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$1,875.20
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$1,875.20
|
|
|
OP INJ OP INJ TRANSFORA L/S 1 64483
|
Facility
IP
|
$2,344.00
|
|
|
Service Code
|
CPT 64483
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,640.80 |
| Max. Negotiated Rate |
$2,344.00 |
| Rate for Payer: AETNA Commercial |
$2,226.80
|
| Rate for Payer: AETNA Medicare |
$2,109.60
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$2,226.80
|
| Rate for Payer: BCBS Healthlink |
$2,109.60
|
| Rate for Payer: BCBS HMK CHIP |
$2,109.60
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$2,109.60
|
| Rate for Payer: BCBS POS |
$2,226.80
|
| Rate for Payer: BCBS Traditional |
$2,344.00
|
| Rate for Payer: CASH_PRICE |
$1,875.20
|
| Rate for Payer: CIGNA Commercial |
$2,226.80
|
| Rate for Payer: CIGNA Medicare |
$2,109.60
|
| Rate for Payer: HUMANA Commercial |
$2,109.60
|
| Rate for Payer: MEDICAID Medicaid |
$2,156.48
|
| Rate for Payer: MEDICARE Medicare |
$1,640.80
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$2,226.80
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$2,273.68
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$2,226.80
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$2,226.80
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$1,992.40
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$1,875.20
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$1,875.20
|
|
|
OP INJ PARAVERT SYMP BLOCK T/L 64520
|
Facility
OP
|
$1,607.00
|
|
|
Service Code
|
CPT 64520
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,124.90 |
| Max. Negotiated Rate |
$1,607.00 |
| Rate for Payer: AETNA Commercial |
$1,526.65
|
| Rate for Payer: AETNA Medicare |
$1,446.30
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$1,526.65
|
| Rate for Payer: BCBS Healthlink |
$1,446.30
|
| Rate for Payer: BCBS HMK CHIP |
$1,446.30
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$1,446.30
|
| Rate for Payer: BCBS POS |
$1,526.65
|
| Rate for Payer: BCBS Traditional |
$1,607.00
|
| Rate for Payer: CASH_PRICE |
$1,285.60
|
| Rate for Payer: CIGNA Commercial |
$1,526.65
|
| Rate for Payer: CIGNA Medicare |
$1,446.30
|
| Rate for Payer: HUMANA Commercial |
$1,446.30
|
| Rate for Payer: MEDICAID Medicaid |
$1,478.44
|
| Rate for Payer: MEDICARE Medicare |
$1,124.90
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$1,526.65
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$1,558.79
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$1,526.65
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$1,526.65
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$1,365.95
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$1,285.60
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$1,285.60
|
|
|
OP INJ PARAVERT SYMP BLOCK T/L 64520
|
Facility
IP
|
$1,607.00
|
|
|
Service Code
|
CPT 64520
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,124.90 |
| Max. Negotiated Rate |
$1,607.00 |
| Rate for Payer: AETNA Commercial |
$1,526.65
|
| Rate for Payer: AETNA Medicare |
$1,446.30
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$1,526.65
|
| Rate for Payer: BCBS Healthlink |
$1,446.30
|
| Rate for Payer: BCBS HMK CHIP |
$1,446.30
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$1,446.30
|
| Rate for Payer: BCBS POS |
$1,526.65
|
| Rate for Payer: BCBS Traditional |
$1,607.00
|
| Rate for Payer: CASH_PRICE |
$1,285.60
|
| Rate for Payer: CIGNA Commercial |
$1,526.65
|
| Rate for Payer: CIGNA Medicare |
$1,446.30
|
| Rate for Payer: HUMANA Commercial |
$1,446.30
|
| Rate for Payer: MEDICAID Medicaid |
$1,478.44
|
| Rate for Payer: MEDICARE Medicare |
$1,124.90
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$1,526.65
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$1,558.79
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$1,526.65
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$1,526.65
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$1,365.95
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$1,285.60
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$1,285.60
|
|
|
OP INJ PLANTAR DIGITAL NERVE BLOCK 64455
|
Facility
OP
|
$173.00
|
|
|
Service Code
|
CPT 64455
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$121.10 |
| Max. Negotiated Rate |
$173.00 |
| Rate for Payer: AETNA Commercial |
$164.35
|
| Rate for Payer: AETNA Medicare |
$155.70
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$164.35
|
| Rate for Payer: BCBS Healthlink |
$155.70
|
| Rate for Payer: BCBS HMK CHIP |
$155.70
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$155.70
|
| Rate for Payer: BCBS POS |
$164.35
|
| Rate for Payer: BCBS Traditional |
$173.00
|
| Rate for Payer: CASH_PRICE |
$138.40
|
| Rate for Payer: CIGNA Commercial |
$164.35
|
| Rate for Payer: CIGNA Medicare |
$155.70
|
| Rate for Payer: HUMANA Commercial |
$155.70
|
| Rate for Payer: MEDICAID Medicaid |
$159.16
|
| Rate for Payer: MEDICARE Medicare |
$121.10
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$164.35
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$167.81
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$164.35
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$164.35
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$147.05
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$138.40
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$138.40
|
|
|
OP INJ PLANTAR DIGITAL NERVE BLOCK 64455
|
Facility
IP
|
$173.00
|
|
|
Service Code
|
CPT 64455
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$121.10 |
| Max. Negotiated Rate |
$173.00 |
| Rate for Payer: AETNA Commercial |
$164.35
|
| Rate for Payer: AETNA Medicare |
$155.70
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$164.35
|
| Rate for Payer: BCBS Healthlink |
$155.70
|
| Rate for Payer: BCBS HMK CHIP |
$155.70
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$155.70
|
| Rate for Payer: BCBS POS |
$164.35
|
| Rate for Payer: BCBS Traditional |
$173.00
|
| Rate for Payer: CASH_PRICE |
$138.40
|
| Rate for Payer: CIGNA Commercial |
$164.35
|
| Rate for Payer: CIGNA Medicare |
$155.70
|
| Rate for Payer: HUMANA Commercial |
$155.70
|
| Rate for Payer: MEDICAID Medicaid |
$159.16
|
| Rate for Payer: MEDICARE Medicare |
$121.10
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$164.35
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$167.81
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$164.35
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$164.35
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$147.05
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$138.40
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$138.40
|
|
|
OP INJ RFA C/T 1ST JOINT 64633
|
Facility
OP
|
$2,198.00
|
|
|
Service Code
|
CPT 64633
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,538.60 |
| Max. Negotiated Rate |
$2,198.00 |
| Rate for Payer: AETNA Commercial |
$2,088.10
|
| Rate for Payer: AETNA Medicare |
$1,978.20
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$2,088.10
|
| Rate for Payer: BCBS Healthlink |
$1,978.20
|
| Rate for Payer: BCBS HMK CHIP |
$1,978.20
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$1,978.20
|
| Rate for Payer: BCBS POS |
$2,088.10
|
| Rate for Payer: BCBS Traditional |
$2,198.00
|
| Rate for Payer: CASH_PRICE |
$1,758.40
|
| Rate for Payer: CIGNA Commercial |
$2,088.10
|
| Rate for Payer: CIGNA Medicare |
$1,978.20
|
| Rate for Payer: HUMANA Commercial |
$1,978.20
|
| Rate for Payer: MEDICAID Medicaid |
$2,022.16
|
| Rate for Payer: MEDICARE Medicare |
$1,538.60
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$2,088.10
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$2,132.06
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$2,088.10
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$2,088.10
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$1,868.30
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$1,758.40
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$1,758.40
|
|
|
OP INJ RFA C/T 1ST JOINT 64633
|
Facility
IP
|
$2,198.00
|
|
|
Service Code
|
CPT 64633
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,538.60 |
| Max. Negotiated Rate |
$2,198.00 |
| Rate for Payer: AETNA Commercial |
$2,088.10
|
| Rate for Payer: AETNA Medicare |
$1,978.20
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$2,088.10
|
| Rate for Payer: BCBS Healthlink |
$1,978.20
|
| Rate for Payer: BCBS HMK CHIP |
$1,978.20
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$1,978.20
|
| Rate for Payer: BCBS POS |
$2,088.10
|
| Rate for Payer: BCBS Traditional |
$2,198.00
|
| Rate for Payer: CASH_PRICE |
$1,758.40
|
| Rate for Payer: CIGNA Commercial |
$2,088.10
|
| Rate for Payer: CIGNA Medicare |
$1,978.20
|
| Rate for Payer: HUMANA Commercial |
$1,978.20
|
| Rate for Payer: MEDICAID Medicaid |
$2,022.16
|
| Rate for Payer: MEDICARE Medicare |
$1,538.60
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$2,088.10
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$2,132.06
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$2,088.10
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$2,088.10
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$1,868.30
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$1,758.40
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$1,758.40
|
|
|
OP INJ RFA C/T EA ADD ON JT 64634
|
Facility
OP
|
$924.00
|
|
|
Service Code
|
CPT 64634
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$646.80 |
| Max. Negotiated Rate |
$924.00 |
| Rate for Payer: AETNA Commercial |
$877.80
|
| Rate for Payer: AETNA Medicare |
$831.60
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$877.80
|
| Rate for Payer: BCBS Healthlink |
$831.60
|
| Rate for Payer: BCBS HMK CHIP |
$831.60
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$831.60
|
| Rate for Payer: BCBS POS |
$877.80
|
| Rate for Payer: BCBS Traditional |
$924.00
|
| Rate for Payer: CASH_PRICE |
$739.20
|
| Rate for Payer: CIGNA Commercial |
$877.80
|
| Rate for Payer: CIGNA Medicare |
$831.60
|
| Rate for Payer: HUMANA Commercial |
$831.60
|
| Rate for Payer: MEDICAID Medicaid |
$850.08
|
| Rate for Payer: MEDICARE Medicare |
$646.80
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$877.80
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$896.28
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$877.80
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$877.80
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$785.40
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$739.20
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$739.20
|
|
|
OP INJ RFA C/T EA ADD ON JT 64634
|
Facility
IP
|
$924.00
|
|
|
Service Code
|
CPT 64634
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$646.80 |
| Max. Negotiated Rate |
$924.00 |
| Rate for Payer: AETNA Commercial |
$877.80
|
| Rate for Payer: AETNA Medicare |
$831.60
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$877.80
|
| Rate for Payer: BCBS Healthlink |
$831.60
|
| Rate for Payer: BCBS HMK CHIP |
$831.60
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$831.60
|
| Rate for Payer: BCBS POS |
$877.80
|
| Rate for Payer: BCBS Traditional |
$924.00
|
| Rate for Payer: CASH_PRICE |
$739.20
|
| Rate for Payer: CIGNA Commercial |
$877.80
|
| Rate for Payer: CIGNA Medicare |
$831.60
|
| Rate for Payer: HUMANA Commercial |
$831.60
|
| Rate for Payer: MEDICAID Medicaid |
$850.08
|
| Rate for Payer: MEDICARE Medicare |
$646.80
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$877.80
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$896.28
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$877.80
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$877.80
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$785.40
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$739.20
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$739.20
|
|
|
OP INJ RFA L/S 1ST JOINT 64635
|
Facility
IP
|
$2,441.00
|
|
|
Service Code
|
CPT 64635
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,708.70 |
| Max. Negotiated Rate |
$2,441.00 |
| Rate for Payer: AETNA Commercial |
$2,318.95
|
| Rate for Payer: AETNA Medicare |
$2,196.90
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$2,318.95
|
| Rate for Payer: BCBS Healthlink |
$2,196.90
|
| Rate for Payer: BCBS HMK CHIP |
$2,196.90
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$2,196.90
|
| Rate for Payer: BCBS POS |
$2,318.95
|
| Rate for Payer: BCBS Traditional |
$2,441.00
|
| Rate for Payer: CASH_PRICE |
$1,952.80
|
| Rate for Payer: CIGNA Commercial |
$2,318.95
|
| Rate for Payer: CIGNA Medicare |
$2,196.90
|
| Rate for Payer: HUMANA Commercial |
$2,196.90
|
| Rate for Payer: MEDICAID Medicaid |
$2,245.72
|
| Rate for Payer: MEDICARE Medicare |
$1,708.70
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$2,318.95
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$2,367.77
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$2,318.95
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$2,318.95
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$2,074.85
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$1,952.80
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$1,952.80
|
|
