|
CT ISOVUE 370 100ML CONTRAST BOTTLE
|
Facility
IP
|
$311.00
|
|
|
Service Code
|
CPT Q9967 TC
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$217.70 |
| Max. Negotiated Rate |
$311.00 |
| Rate for Payer: AETNA Commercial |
$295.45
|
| Rate for Payer: AETNA Medicare |
$279.90
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$295.45
|
| Rate for Payer: BCBS Healthlink |
$279.90
|
| Rate for Payer: BCBS HMK CHIP |
$279.90
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$279.90
|
| Rate for Payer: BCBS POS |
$295.45
|
| Rate for Payer: BCBS Traditional |
$311.00
|
| Rate for Payer: CASH_PRICE |
$248.80
|
| Rate for Payer: CIGNA Commercial |
$295.45
|
| Rate for Payer: CIGNA Medicare |
$279.90
|
| Rate for Payer: HUMANA Commercial |
$279.90
|
| Rate for Payer: MEDICAID Medicaid |
$286.12
|
| Rate for Payer: MEDICARE Medicare |
$217.70
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$295.45
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$301.67
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$295.45
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$295.45
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$264.35
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$248.80
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$248.80
|
|
|
CT ISOVUE 370 100ML CONTRAST BOTTLE
|
Facility
OP
|
$311.00
|
|
|
Service Code
|
CPT Q9967 TC
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$217.70 |
| Max. Negotiated Rate |
$311.00 |
| Rate for Payer: AETNA Commercial |
$295.45
|
| Rate for Payer: AETNA Medicare |
$279.90
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$295.45
|
| Rate for Payer: BCBS Healthlink |
$279.90
|
| Rate for Payer: BCBS HMK CHIP |
$279.90
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$279.90
|
| Rate for Payer: BCBS POS |
$295.45
|
| Rate for Payer: BCBS Traditional |
$311.00
|
| Rate for Payer: CASH_PRICE |
$248.80
|
| Rate for Payer: CIGNA Commercial |
$295.45
|
| Rate for Payer: CIGNA Medicare |
$279.90
|
| Rate for Payer: HUMANA Commercial |
$279.90
|
| Rate for Payer: MEDICAID Medicaid |
$286.12
|
| Rate for Payer: MEDICARE Medicare |
$217.70
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$295.45
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$301.67
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$295.45
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$295.45
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$264.35
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$248.80
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$248.80
|
|
|
CT LIMITED FOLLOW-UP
|
Facility
OP
|
$737.00
|
|
|
Service Code
|
CPT 76380 TC
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$515.90 |
| Max. Negotiated Rate |
$737.00 |
| Rate for Payer: AETNA Commercial |
$700.15
|
| Rate for Payer: AETNA Medicare |
$663.30
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$700.15
|
| Rate for Payer: BCBS Healthlink |
$663.30
|
| Rate for Payer: BCBS HMK CHIP |
$663.30
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$663.30
|
| Rate for Payer: BCBS POS |
$700.15
|
| Rate for Payer: BCBS Traditional |
$737.00
|
| Rate for Payer: CASH_PRICE |
$589.60
|
| Rate for Payer: CIGNA Commercial |
$700.15
|
| Rate for Payer: CIGNA Medicare |
$663.30
|
| Rate for Payer: HUMANA Commercial |
$663.30
|
| Rate for Payer: MEDICAID Medicaid |
$678.04
|
| Rate for Payer: MEDICARE Medicare |
$515.90
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$700.15
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$714.89
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$700.15
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$700.15
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$626.45
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$589.60
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$589.60
|
|
|
CT LIMITED FOLLOW-UP
|
Facility
IP
|
$737.00
|
|
|
Service Code
|
CPT 76380 TC
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$515.90 |
| Max. Negotiated Rate |
$737.00 |
| Rate for Payer: BCBS HMK CHIP |
$663.30
|
| Rate for Payer: AETNA Commercial |
$700.15
|
| Rate for Payer: AETNA Medicare |
$663.30
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$700.15
|
| Rate for Payer: BCBS Healthlink |
$663.30
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$663.30
|
| Rate for Payer: BCBS POS |
$700.15
|
| Rate for Payer: BCBS Traditional |
$737.00
|
| Rate for Payer: CASH_PRICE |
$589.60
|
| Rate for Payer: CIGNA Commercial |
$700.15
|
| Rate for Payer: CIGNA Medicare |
$663.30
|
| Rate for Payer: HUMANA Commercial |
$663.30
|
| Rate for Payer: MEDICAID Medicaid |
$678.04
|
| Rate for Payer: MEDICARE Medicare |
$515.90
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$700.15
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$714.89
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$700.15
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$700.15
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$626.45
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$589.60
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$589.60
|
|
|
CT LIMITED ORBITS FOR MRI
|
Facility
IP
|
$911.00
|
|
|
Service Code
|
CPT 70480 TC
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$637.70 |
| Max. Negotiated Rate |
$911.00 |
| Rate for Payer: AETNA Commercial |
$865.45
|
| Rate for Payer: AETNA Medicare |
$819.90
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$865.45
|
| Rate for Payer: BCBS Healthlink |
$819.90
|
| Rate for Payer: BCBS HMK CHIP |
$819.90
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$819.90
|
| Rate for Payer: BCBS POS |
$865.45
|
| Rate for Payer: BCBS Traditional |
$911.00
|
| Rate for Payer: CASH_PRICE |
$728.80
|
| Rate for Payer: CIGNA Commercial |
$865.45
|
| Rate for Payer: CIGNA Medicare |
$819.90
|
| Rate for Payer: HUMANA Commercial |
$819.90
|
| Rate for Payer: MEDICAID Medicaid |
$838.12
|
| Rate for Payer: MEDICARE Medicare |
$637.70
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$865.45
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$883.67
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$865.45
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$865.45
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$774.35
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$728.80
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$728.80
|
|
|
CT LIMITED ORBITS FOR MRI
|
Facility
OP
|
$911.00
|
|
|
Service Code
|
CPT 70480 TC
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$637.70 |
| Max. Negotiated Rate |
$911.00 |
| Rate for Payer: AETNA Commercial |
$865.45
|
| Rate for Payer: AETNA Medicare |
$819.90
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$865.45
|
| Rate for Payer: BCBS Healthlink |
$819.90
|
| Rate for Payer: BCBS HMK CHIP |
$819.90
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$819.90
|
| Rate for Payer: BCBS POS |
$865.45
|
| Rate for Payer: BCBS Traditional |
$911.00
|
| Rate for Payer: CASH_PRICE |
$728.80
|
| Rate for Payer: CIGNA Commercial |
$865.45
|
| Rate for Payer: CIGNA Medicare |
$819.90
|
| Rate for Payer: HUMANA Commercial |
$819.90
|
| Rate for Payer: MEDICAID Medicaid |
$838.12
|
| Rate for Payer: MEDICARE Medicare |
$637.70
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$865.45
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$883.67
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$865.45
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$865.45
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$774.35
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$728.80
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$728.80
|
|
|
CT LOW DOSE LUNG SCREEN
|
Facility
OP
|
$464.00
|
|
|
Service Code
|
CPT 71271 TC
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$324.80 |
| Max. Negotiated Rate |
$464.00 |
| Rate for Payer: AETNA Commercial |
$440.80
|
| Rate for Payer: AETNA Medicare |
$417.60
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$440.80
|
| Rate for Payer: BCBS Healthlink |
$417.60
|
| Rate for Payer: BCBS HMK CHIP |
$417.60
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$417.60
|
| Rate for Payer: BCBS POS |
$440.80
|
| Rate for Payer: BCBS Traditional |
$464.00
|
| Rate for Payer: CASH_PRICE |
$371.20
|
| Rate for Payer: CIGNA Commercial |
$440.80
|
| Rate for Payer: CIGNA Medicare |
$417.60
|
| Rate for Payer: HUMANA Commercial |
$417.60
|
| Rate for Payer: MEDICAID Medicaid |
$426.88
|
| Rate for Payer: MEDICARE Medicare |
$324.80
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$440.80
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$450.08
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$440.80
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$440.80
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$394.40
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$371.20
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$371.20
|
|
|
CT LOW DOSE LUNG SCREEN
|
Facility
IP
|
$464.00
|
|
|
Service Code
|
CPT 71271 TC
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$324.80 |
| Max. Negotiated Rate |
$464.00 |
| Rate for Payer: BCBS HMK CHIP |
$417.60
|
| Rate for Payer: AETNA Commercial |
$440.80
|
| Rate for Payer: AETNA Medicare |
$417.60
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$440.80
|
| Rate for Payer: BCBS Healthlink |
$417.60
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$417.60
|
| Rate for Payer: BCBS POS |
$440.80
|
| Rate for Payer: BCBS Traditional |
$464.00
|
| Rate for Payer: CASH_PRICE |
$371.20
|
| Rate for Payer: CIGNA Commercial |
$440.80
|
| Rate for Payer: CIGNA Medicare |
$417.60
|
| Rate for Payer: HUMANA Commercial |
$417.60
|
| Rate for Payer: MEDICAID Medicaid |
$426.88
|
| Rate for Payer: MEDICARE Medicare |
$324.80
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$440.80
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$450.08
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$440.80
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$440.80
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$394.40
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$371.20
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$371.20
|
|
|
CT LOWER EXTREMITY LT W CONTRAST
|
Facility
IP
|
$1,819.00
|
|
|
Service Code
|
CPT 73701 LT
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$1,273.30 |
| Max. Negotiated Rate |
$1,819.00 |
| Rate for Payer: AETNA Commercial |
$1,728.05
|
| Rate for Payer: AETNA Medicare |
$1,637.10
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$1,728.05
|
| Rate for Payer: BCBS Healthlink |
$1,637.10
|
| Rate for Payer: BCBS HMK CHIP |
$1,637.10
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$1,637.10
|
| Rate for Payer: BCBS POS |
$1,728.05
|
| Rate for Payer: BCBS Traditional |
$1,819.00
|
| Rate for Payer: CASH_PRICE |
$1,455.20
|
| Rate for Payer: CIGNA Commercial |
$1,728.05
|
| Rate for Payer: CIGNA Medicare |
$1,637.10
|
| Rate for Payer: HUMANA Commercial |
$1,637.10
|
| Rate for Payer: MEDICAID Medicaid |
$1,673.48
|
| Rate for Payer: MEDICARE Medicare |
$1,273.30
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$1,728.05
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$1,764.43
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$1,728.05
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$1,728.05
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$1,546.15
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$1,455.20
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$1,455.20
|
|
|
CT LOWER EXTREMITY LT W CONTRAST
|
Facility
OP
|
$1,819.00
|
|
|
Service Code
|
CPT 73701 LT
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$1,273.30 |
| Max. Negotiated Rate |
$1,819.00 |
| Rate for Payer: AETNA Commercial |
$1,728.05
|
| Rate for Payer: AETNA Medicare |
$1,637.10
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$1,728.05
|
| Rate for Payer: BCBS Healthlink |
$1,637.10
|
| Rate for Payer: BCBS HMK CHIP |
$1,637.10
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$1,637.10
|
| Rate for Payer: BCBS POS |
$1,728.05
|
| Rate for Payer: BCBS Traditional |
$1,819.00
|
| Rate for Payer: CASH_PRICE |
$1,455.20
|
| Rate for Payer: CIGNA Commercial |
$1,728.05
|
| Rate for Payer: CIGNA Medicare |
$1,637.10
|
| Rate for Payer: HUMANA Commercial |
$1,637.10
|
| Rate for Payer: MEDICAID Medicaid |
$1,673.48
|
| Rate for Payer: MEDICARE Medicare |
$1,273.30
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$1,728.05
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$1,764.43
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$1,728.05
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$1,728.05
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$1,546.15
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$1,455.20
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$1,455.20
|
|
|
CT LOWER EXTREMITY LT WO CONTRAST
|
Facility
IP
|
$1,474.00
|
|
|
Service Code
|
CPT 73700 RT
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$1,031.80 |
| Max. Negotiated Rate |
$1,474.00 |
| Rate for Payer: AETNA Commercial |
$1,400.30
|
| Rate for Payer: AETNA Medicare |
$1,326.60
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$1,400.30
|
| Rate for Payer: BCBS Healthlink |
$1,326.60
|
| Rate for Payer: BCBS HMK CHIP |
$1,326.60
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$1,326.60
|
| Rate for Payer: BCBS POS |
$1,400.30
|
| Rate for Payer: BCBS Traditional |
$1,474.00
|
| Rate for Payer: CASH_PRICE |
$1,179.20
|
| Rate for Payer: CIGNA Commercial |
$1,400.30
|
| Rate for Payer: CIGNA Medicare |
$1,326.60
|
| Rate for Payer: HUMANA Commercial |
$1,326.60
|
| Rate for Payer: MEDICAID Medicaid |
$1,356.08
|
| Rate for Payer: MEDICARE Medicare |
$1,031.80
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$1,400.30
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$1,429.78
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$1,400.30
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$1,400.30
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$1,252.90
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$1,179.20
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$1,179.20
|
|
|
CT LOWER EXTREMITY LT WO CONTRAST
|
Facility
OP
|
$1,474.00
|
|
|
Service Code
|
CPT 73700 RT
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$1,031.80 |
| Max. Negotiated Rate |
$1,474.00 |
| Rate for Payer: AETNA Commercial |
$1,400.30
|
| Rate for Payer: AETNA Medicare |
$1,326.60
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$1,400.30
|
| Rate for Payer: BCBS Healthlink |
$1,326.60
|
| Rate for Payer: BCBS HMK CHIP |
$1,326.60
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$1,326.60
|
| Rate for Payer: BCBS POS |
$1,400.30
|
| Rate for Payer: BCBS Traditional |
$1,474.00
|
| Rate for Payer: CASH_PRICE |
$1,179.20
|
| Rate for Payer: CIGNA Commercial |
$1,400.30
|
| Rate for Payer: CIGNA Medicare |
$1,326.60
|
| Rate for Payer: HUMANA Commercial |
$1,326.60
|
| Rate for Payer: MEDICAID Medicaid |
$1,356.08
|
| Rate for Payer: MEDICARE Medicare |
$1,031.80
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$1,400.30
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$1,429.78
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$1,400.30
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$1,400.30
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$1,252.90
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$1,179.20
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$1,179.20
|
|
|
CT LOWER EXTREMITY LT W WO CONTRAST
|
Facility
IP
|
$2,167.00
|
|
|
Service Code
|
CPT 73702 LT
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$1,516.90 |
| Max. Negotiated Rate |
$2,167.00 |
| Rate for Payer: BCBS HMK CHIP |
$1,950.30
|
| Rate for Payer: AETNA Commercial |
$2,058.65
|
| Rate for Payer: AETNA Medicare |
$1,950.30
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$2,058.65
|
| Rate for Payer: BCBS Healthlink |
$1,950.30
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$1,950.30
|
| Rate for Payer: BCBS POS |
$2,058.65
|
| Rate for Payer: BCBS Traditional |
$2,167.00
|
| Rate for Payer: CASH_PRICE |
$1,733.60
|
| Rate for Payer: CIGNA Commercial |
$2,058.65
|
| Rate for Payer: CIGNA Medicare |
$1,950.30
|
| Rate for Payer: HUMANA Commercial |
$1,950.30
|
| Rate for Payer: MEDICAID Medicaid |
$1,993.64
|
| Rate for Payer: MEDICARE Medicare |
$1,516.90
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$2,058.65
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$2,101.99
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$2,058.65
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$2,058.65
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$1,841.95
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$1,733.60
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$1,733.60
|
|
|
CT LOWER EXTREMITY LT W WO CONTRAST
|
Facility
OP
|
$2,167.00
|
|
|
Service Code
|
CPT 73702 LT
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$1,516.90 |
| Max. Negotiated Rate |
$2,167.00 |
| Rate for Payer: AETNA Commercial |
$2,058.65
|
| Rate for Payer: AETNA Medicare |
$1,950.30
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$2,058.65
|
| Rate for Payer: BCBS Healthlink |
$1,950.30
|
| Rate for Payer: BCBS HMK CHIP |
$1,950.30
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$1,950.30
|
| Rate for Payer: BCBS POS |
$2,058.65
|
| Rate for Payer: BCBS Traditional |
$2,167.00
|
| Rate for Payer: CASH_PRICE |
$1,733.60
|
| Rate for Payer: CIGNA Commercial |
$2,058.65
|
| Rate for Payer: CIGNA Medicare |
$1,950.30
|
| Rate for Payer: HUMANA Commercial |
$1,950.30
|
| Rate for Payer: MEDICAID Medicaid |
$1,993.64
|
| Rate for Payer: MEDICARE Medicare |
$1,516.90
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$2,058.65
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$2,101.99
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$2,058.65
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$2,058.65
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$1,841.95
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$1,733.60
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$1,733.60
|
|
|
CT LOWER EXTREMITY RT W CONTRAST
|
Facility
OP
|
$1,819.00
|
|
|
Service Code
|
CPT 73701 RT
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$1,273.30 |
| Max. Negotiated Rate |
$1,819.00 |
| Rate for Payer: AETNA Commercial |
$1,728.05
|
| Rate for Payer: AETNA Medicare |
$1,637.10
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$1,728.05
|
| Rate for Payer: BCBS Healthlink |
$1,637.10
|
| Rate for Payer: BCBS HMK CHIP |
$1,637.10
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$1,637.10
|
| Rate for Payer: BCBS POS |
$1,728.05
|
| Rate for Payer: BCBS Traditional |
$1,819.00
|
| Rate for Payer: CASH_PRICE |
$1,455.20
|
| Rate for Payer: CIGNA Commercial |
$1,728.05
|
| Rate for Payer: CIGNA Medicare |
$1,637.10
|
| Rate for Payer: HUMANA Commercial |
$1,637.10
|
| Rate for Payer: MEDICAID Medicaid |
$1,673.48
|
| Rate for Payer: MEDICARE Medicare |
$1,273.30
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$1,728.05
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$1,764.43
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$1,728.05
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$1,728.05
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$1,546.15
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$1,455.20
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$1,455.20
|
|
|
CT LOWER EXTREMITY RT W CONTRAST
|
Facility
IP
|
$1,819.00
|
|
|
Service Code
|
CPT 73701 RT
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$1,273.30 |
| Max. Negotiated Rate |
$1,819.00 |
| Rate for Payer: BCBS HMK CHIP |
$1,637.10
|
| Rate for Payer: AETNA Commercial |
$1,728.05
|
| Rate for Payer: AETNA Medicare |
$1,637.10
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$1,728.05
|
| Rate for Payer: BCBS Healthlink |
$1,637.10
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$1,637.10
|
| Rate for Payer: BCBS POS |
$1,728.05
|
| Rate for Payer: BCBS Traditional |
$1,819.00
|
| Rate for Payer: CASH_PRICE |
$1,455.20
|
| Rate for Payer: CIGNA Commercial |
$1,728.05
|
| Rate for Payer: CIGNA Medicare |
$1,637.10
|
| Rate for Payer: HUMANA Commercial |
$1,637.10
|
| Rate for Payer: MEDICAID Medicaid |
$1,673.48
|
| Rate for Payer: MEDICARE Medicare |
$1,273.30
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$1,728.05
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$1,764.43
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$1,728.05
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$1,728.05
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$1,546.15
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$1,455.20
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$1,455.20
|
|
|
CT LOWER EXTREMITY RT WO CONTRAST
|
Facility
IP
|
$1,474.00
|
|
|
Service Code
|
CPT 73700 RT
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$1,031.80 |
| Max. Negotiated Rate |
$1,474.00 |
| Rate for Payer: BCBS HMK CHIP |
$1,326.60
|
| Rate for Payer: AETNA Commercial |
$1,400.30
|
| Rate for Payer: AETNA Medicare |
$1,326.60
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$1,400.30
|
| Rate for Payer: BCBS Healthlink |
$1,326.60
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$1,326.60
|
| Rate for Payer: BCBS POS |
$1,400.30
|
| Rate for Payer: BCBS Traditional |
$1,474.00
|
| Rate for Payer: CASH_PRICE |
$1,179.20
|
| Rate for Payer: CIGNA Commercial |
$1,400.30
|
| Rate for Payer: CIGNA Medicare |
$1,326.60
|
| Rate for Payer: HUMANA Commercial |
$1,326.60
|
| Rate for Payer: MEDICAID Medicaid |
$1,356.08
|
| Rate for Payer: MEDICARE Medicare |
$1,031.80
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$1,400.30
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$1,429.78
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$1,400.30
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$1,400.30
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$1,252.90
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$1,179.20
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$1,179.20
|
|
|
CT LOWER EXTREMITY RT WO CONTRAST
|
Facility
OP
|
$1,474.00
|
|
|
Service Code
|
CPT 73700 RT
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$1,031.80 |
| Max. Negotiated Rate |
$1,474.00 |
| Rate for Payer: AETNA Commercial |
$1,400.30
|
| Rate for Payer: AETNA Medicare |
$1,326.60
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$1,400.30
|
| Rate for Payer: BCBS Healthlink |
$1,326.60
|
| Rate for Payer: BCBS HMK CHIP |
$1,326.60
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$1,326.60
|
| Rate for Payer: BCBS POS |
$1,400.30
|
| Rate for Payer: BCBS Traditional |
$1,474.00
|
| Rate for Payer: CASH_PRICE |
$1,179.20
|
| Rate for Payer: CIGNA Commercial |
$1,400.30
|
| Rate for Payer: CIGNA Medicare |
$1,326.60
|
| Rate for Payer: HUMANA Commercial |
$1,326.60
|
| Rate for Payer: MEDICAID Medicaid |
$1,356.08
|
| Rate for Payer: MEDICARE Medicare |
$1,031.80
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$1,400.30
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$1,429.78
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$1,400.30
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$1,400.30
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$1,252.90
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$1,179.20
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$1,179.20
|
|
|
CT LOWER EXTREMITY RT W WO CONTRAST
|
Facility
IP
|
$2,167.00
|
|
|
Service Code
|
CPT 73702 RT
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$1,516.90 |
| Max. Negotiated Rate |
$2,167.00 |
| Rate for Payer: AETNA Commercial |
$2,058.65
|
| Rate for Payer: AETNA Medicare |
$1,950.30
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$2,058.65
|
| Rate for Payer: BCBS Healthlink |
$1,950.30
|
| Rate for Payer: BCBS HMK CHIP |
$1,950.30
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$1,950.30
|
| Rate for Payer: BCBS POS |
$2,058.65
|
| Rate for Payer: BCBS Traditional |
$2,167.00
|
| Rate for Payer: CASH_PRICE |
$1,733.60
|
| Rate for Payer: CIGNA Commercial |
$2,058.65
|
| Rate for Payer: CIGNA Medicare |
$1,950.30
|
| Rate for Payer: HUMANA Commercial |
$1,950.30
|
| Rate for Payer: MEDICAID Medicaid |
$1,993.64
|
| Rate for Payer: MEDICARE Medicare |
$1,516.90
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$2,058.65
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$2,101.99
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$2,058.65
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$2,058.65
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$1,841.95
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$1,733.60
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$1,733.60
|
|
|
CT LOWER EXTREMITY RT W WO CONTRAST
|
Facility
OP
|
$2,167.00
|
|
|
Service Code
|
CPT 73702 RT
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$1,516.90 |
| Max. Negotiated Rate |
$2,167.00 |
| Rate for Payer: AETNA Commercial |
$2,058.65
|
| Rate for Payer: AETNA Medicare |
$1,950.30
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$2,058.65
|
| Rate for Payer: BCBS Healthlink |
$1,950.30
|
| Rate for Payer: BCBS HMK CHIP |
$1,950.30
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$1,950.30
|
| Rate for Payer: BCBS POS |
$2,058.65
|
| Rate for Payer: BCBS Traditional |
$2,167.00
|
| Rate for Payer: CASH_PRICE |
$1,733.60
|
| Rate for Payer: CIGNA Commercial |
$2,058.65
|
| Rate for Payer: CIGNA Medicare |
$1,950.30
|
| Rate for Payer: HUMANA Commercial |
$1,950.30
|
| Rate for Payer: MEDICAID Medicaid |
$1,993.64
|
| Rate for Payer: MEDICARE Medicare |
$1,516.90
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$2,058.65
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$2,101.99
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$2,058.65
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$2,058.65
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$1,841.95
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$1,733.60
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$1,733.60
|
|
|
CT LUMBAR SPINE W CONTRAST
|
Facility
OP
|
$2,042.00
|
|
|
Service Code
|
CPT 72132 TC
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$1,429.40 |
| Max. Negotiated Rate |
$2,042.00 |
| Rate for Payer: AETNA Commercial |
$1,939.90
|
| Rate for Payer: AETNA Medicare |
$1,837.80
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$1,939.90
|
| Rate for Payer: BCBS Healthlink |
$1,837.80
|
| Rate for Payer: BCBS HMK CHIP |
$1,837.80
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$1,837.80
|
| Rate for Payer: BCBS POS |
$1,939.90
|
| Rate for Payer: BCBS Traditional |
$2,042.00
|
| Rate for Payer: CASH_PRICE |
$1,633.60
|
| Rate for Payer: CIGNA Commercial |
$1,939.90
|
| Rate for Payer: CIGNA Medicare |
$1,837.80
|
| Rate for Payer: HUMANA Commercial |
$1,837.80
|
| Rate for Payer: MEDICAID Medicaid |
$1,878.64
|
| Rate for Payer: MEDICARE Medicare |
$1,429.40
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$1,939.90
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$1,980.74
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$1,939.90
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$1,939.90
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$1,735.70
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$1,633.60
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$1,633.60
|
|
|
CT LUMBAR SPINE W CONTRAST
|
Facility
IP
|
$2,042.00
|
|
|
Service Code
|
CPT 72132 TC
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$1,429.40 |
| Max. Negotiated Rate |
$2,042.00 |
| Rate for Payer: AETNA Commercial |
$1,939.90
|
| Rate for Payer: AETNA Medicare |
$1,837.80
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$1,939.90
|
| Rate for Payer: BCBS Healthlink |
$1,837.80
|
| Rate for Payer: BCBS HMK CHIP |
$1,837.80
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$1,837.80
|
| Rate for Payer: BCBS POS |
$1,939.90
|
| Rate for Payer: BCBS Traditional |
$2,042.00
|
| Rate for Payer: CASH_PRICE |
$1,633.60
|
| Rate for Payer: CIGNA Commercial |
$1,939.90
|
| Rate for Payer: CIGNA Medicare |
$1,837.80
|
| Rate for Payer: HUMANA Commercial |
$1,837.80
|
| Rate for Payer: MEDICAID Medicaid |
$1,878.64
|
| Rate for Payer: MEDICARE Medicare |
$1,429.40
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$1,939.90
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$1,980.74
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$1,939.90
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$1,939.90
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$1,735.70
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$1,633.60
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$1,633.60
|
|
|
CT LUMBAR SPINE WO CONTRAST
|
Facility
OP
|
$1,616.00
|
|
|
Service Code
|
CPT 72131 TC
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$1,131.20 |
| Max. Negotiated Rate |
$1,616.00 |
| Rate for Payer: AETNA Commercial |
$1,535.20
|
| Rate for Payer: AETNA Medicare |
$1,454.40
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$1,535.20
|
| Rate for Payer: BCBS Healthlink |
$1,454.40
|
| Rate for Payer: BCBS HMK CHIP |
$1,454.40
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$1,454.40
|
| Rate for Payer: BCBS POS |
$1,535.20
|
| Rate for Payer: BCBS Traditional |
$1,616.00
|
| Rate for Payer: CASH_PRICE |
$1,292.80
|
| Rate for Payer: CIGNA Commercial |
$1,535.20
|
| Rate for Payer: CIGNA Medicare |
$1,454.40
|
| Rate for Payer: HUMANA Commercial |
$1,454.40
|
| Rate for Payer: MEDICAID Medicaid |
$1,486.72
|
| Rate for Payer: MEDICARE Medicare |
$1,131.20
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$1,535.20
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$1,567.52
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$1,535.20
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$1,535.20
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$1,373.60
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$1,292.80
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$1,292.80
|
|
|
CT LUMBAR SPINE WO CONTRAST
|
Facility
IP
|
$1,616.00
|
|
|
Service Code
|
CPT 72131 TC
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$1,131.20 |
| Max. Negotiated Rate |
$1,616.00 |
| Rate for Payer: AETNA Commercial |
$1,535.20
|
| Rate for Payer: AETNA Medicare |
$1,454.40
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$1,535.20
|
| Rate for Payer: BCBS Healthlink |
$1,454.40
|
| Rate for Payer: BCBS HMK CHIP |
$1,454.40
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$1,454.40
|
| Rate for Payer: BCBS POS |
$1,535.20
|
| Rate for Payer: BCBS Traditional |
$1,616.00
|
| Rate for Payer: CASH_PRICE |
$1,292.80
|
| Rate for Payer: CIGNA Commercial |
$1,535.20
|
| Rate for Payer: CIGNA Medicare |
$1,454.40
|
| Rate for Payer: HUMANA Commercial |
$1,454.40
|
| Rate for Payer: MEDICAID Medicaid |
$1,486.72
|
| Rate for Payer: MEDICARE Medicare |
$1,131.20
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$1,535.20
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$1,567.52
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$1,535.20
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$1,535.20
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$1,373.60
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$1,292.80
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$1,292.80
|
|
|
CT LUMBAR SPINE W WO CONTRAST
|
Facility
IP
|
$2,343.00
|
|
|
Service Code
|
CPT 72133 TC
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$1,640.10 |
| Max. Negotiated Rate |
$2,343.00 |
| Rate for Payer: BCBS HMK CHIP |
$2,108.70
|
| Rate for Payer: AETNA Commercial |
$2,225.85
|
| Rate for Payer: AETNA Medicare |
$2,108.70
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$2,225.85
|
| Rate for Payer: BCBS Healthlink |
$2,108.70
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$2,108.70
|
| Rate for Payer: BCBS POS |
$2,225.85
|
| Rate for Payer: BCBS Traditional |
$2,343.00
|
| Rate for Payer: CASH_PRICE |
$1,874.40
|
| Rate for Payer: CIGNA Commercial |
$2,225.85
|
| Rate for Payer: CIGNA Medicare |
$2,108.70
|
| Rate for Payer: HUMANA Commercial |
$2,108.70
|
| Rate for Payer: MEDICAID Medicaid |
$2,155.56
|
| Rate for Payer: MEDICARE Medicare |
$1,640.10
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$2,225.85
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$2,272.71
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$2,225.85
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$2,225.85
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$1,991.55
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$1,874.40
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$1,874.40
|
|
