|
CT LUMBAR SPINE W WO CONTRAST
|
Facility
OP
|
$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: 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 HMK CHIP |
$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
|
|
|
CT OMNIPAQUE CONTRAST 350 ML
|
Facility
OP
|
$311.00
|
|
|
Service Code
|
CPT Q9967
|
| 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 OMNIPAQUE CONTRAST 350 ML
|
Facility
IP
|
$311.00
|
|
|
Service Code
|
CPT Q9967
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$217.70 |
| Max. Negotiated Rate |
$311.00 |
| Rate for Payer: BCBS HMK CHIP |
$279.90
|
| 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 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 ORBIT EAR FOSSA W WO CONTRAST
|
Facility
OP
|
$2,113.00
|
|
|
Service Code
|
CPT 70482 TC
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$1,479.10 |
| Max. Negotiated Rate |
$2,113.00 |
| Rate for Payer: AETNA Commercial |
$2,007.35
|
| Rate for Payer: AETNA Medicare |
$1,901.70
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$2,007.35
|
| Rate for Payer: BCBS Healthlink |
$1,901.70
|
| Rate for Payer: BCBS HMK CHIP |
$1,901.70
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$1,901.70
|
| Rate for Payer: BCBS POS |
$2,007.35
|
| Rate for Payer: BCBS Traditional |
$2,113.00
|
| Rate for Payer: CASH_PRICE |
$1,690.40
|
| Rate for Payer: CIGNA Commercial |
$2,007.35
|
| Rate for Payer: CIGNA Medicare |
$1,901.70
|
| Rate for Payer: HUMANA Commercial |
$1,901.70
|
| Rate for Payer: MEDICAID Medicaid |
$1,943.96
|
| Rate for Payer: MEDICARE Medicare |
$1,479.10
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$2,007.35
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$2,049.61
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$2,007.35
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$2,007.35
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$1,796.05
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$1,690.40
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$1,690.40
|
|
|
CT ORBIT EAR FOSSA W WO CONTRAST
|
Facility
IP
|
$2,113.00
|
|
|
Service Code
|
CPT 70482 TC
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$1,479.10 |
| Max. Negotiated Rate |
$2,113.00 |
| Rate for Payer: AETNA Commercial |
$2,007.35
|
| Rate for Payer: AETNA Medicare |
$1,901.70
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$2,007.35
|
| Rate for Payer: BCBS Healthlink |
$1,901.70
|
| Rate for Payer: BCBS HMK CHIP |
$1,901.70
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$1,901.70
|
| Rate for Payer: BCBS POS |
$2,007.35
|
| Rate for Payer: BCBS Traditional |
$2,113.00
|
| Rate for Payer: CASH_PRICE |
$1,690.40
|
| Rate for Payer: CIGNA Commercial |
$2,007.35
|
| Rate for Payer: CIGNA Medicare |
$1,901.70
|
| Rate for Payer: HUMANA Commercial |
$1,901.70
|
| Rate for Payer: MEDICAID Medicaid |
$1,943.96
|
| Rate for Payer: MEDICARE Medicare |
$1,479.10
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$2,007.35
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$2,049.61
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$2,007.35
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$2,007.35
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$1,796.05
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$1,690.40
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$1,690.40
|
|
|
CT ORBITS SELLA FOSSA WO CONTRAST
|
Facility
OP
|
$1,512.00
|
|
|
Service Code
|
CPT 70480 TC
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$1,058.40 |
| Max. Negotiated Rate |
$1,512.00 |
| Rate for Payer: AETNA Commercial |
$1,436.40
|
| Rate for Payer: AETNA Medicare |
$1,360.80
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$1,436.40
|
| Rate for Payer: BCBS Healthlink |
$1,360.80
|
| Rate for Payer: BCBS HMK CHIP |
$1,360.80
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$1,360.80
|
| Rate for Payer: BCBS POS |
$1,436.40
|
| Rate for Payer: BCBS Traditional |
$1,512.00
|
| Rate for Payer: CASH_PRICE |
$1,209.60
|
| Rate for Payer: CIGNA Commercial |
$1,436.40
|
| Rate for Payer: CIGNA Medicare |
$1,360.80
|
| Rate for Payer: HUMANA Commercial |
$1,360.80
|
| Rate for Payer: MEDICAID Medicaid |
$1,391.04
|
| Rate for Payer: MEDICARE Medicare |
$1,058.40
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$1,436.40
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$1,466.64
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$1,436.40
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$1,436.40
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$1,285.20
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$1,209.60
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$1,209.60
|
|
|
CT ORBITS SELLA FOSSA WO CONTRAST
|
Facility
IP
|
$1,512.00
|
|
|
Service Code
|
CPT 70480 TC
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$1,058.40 |
| Max. Negotiated Rate |
$1,512.00 |
| Rate for Payer: BCBS HMK CHIP |
$1,360.80
|
| Rate for Payer: AETNA Commercial |
$1,436.40
|
| Rate for Payer: AETNA Medicare |
$1,360.80
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$1,436.40
|
| Rate for Payer: BCBS Healthlink |
$1,360.80
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$1,360.80
|
| Rate for Payer: BCBS POS |
$1,436.40
|
| Rate for Payer: BCBS Traditional |
$1,512.00
|
| Rate for Payer: CASH_PRICE |
$1,209.60
|
| Rate for Payer: CIGNA Commercial |
$1,436.40
|
| Rate for Payer: CIGNA Medicare |
$1,360.80
|
| Rate for Payer: HUMANA Commercial |
$1,360.80
|
| Rate for Payer: MEDICAID Medicaid |
$1,391.04
|
| Rate for Payer: MEDICARE Medicare |
$1,058.40
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$1,436.40
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$1,466.64
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$1,436.40
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$1,436.40
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$1,285.20
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$1,209.60
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$1,209.60
|
|
|
CT PELVIS W CONTRAST
|
Facility
OP
|
$1,966.00
|
|
|
Service Code
|
CPT 72193 TC
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$1,376.20 |
| Max. Negotiated Rate |
$1,966.00 |
| Rate for Payer: AETNA Commercial |
$1,867.70
|
| Rate for Payer: AETNA Medicare |
$1,769.40
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$1,867.70
|
| Rate for Payer: BCBS Healthlink |
$1,769.40
|
| Rate for Payer: BCBS HMK CHIP |
$1,769.40
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$1,769.40
|
| Rate for Payer: BCBS POS |
$1,867.70
|
| Rate for Payer: BCBS Traditional |
$1,966.00
|
| Rate for Payer: CASH_PRICE |
$1,572.80
|
| Rate for Payer: CIGNA Commercial |
$1,867.70
|
| Rate for Payer: CIGNA Medicare |
$1,769.40
|
| Rate for Payer: HUMANA Commercial |
$1,769.40
|
| Rate for Payer: MEDICAID Medicaid |
$1,808.72
|
| Rate for Payer: MEDICARE Medicare |
$1,376.20
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$1,867.70
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$1,907.02
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$1,867.70
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$1,867.70
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$1,671.10
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$1,572.80
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$1,572.80
|
|
|
CT PELVIS W CONTRAST
|
Facility
IP
|
$1,966.00
|
|
|
Service Code
|
CPT 72193 TC
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$1,376.20 |
| Max. Negotiated Rate |
$1,966.00 |
| Rate for Payer: AETNA Commercial |
$1,867.70
|
| Rate for Payer: AETNA Medicare |
$1,769.40
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$1,867.70
|
| Rate for Payer: BCBS Healthlink |
$1,769.40
|
| Rate for Payer: BCBS HMK CHIP |
$1,769.40
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$1,769.40
|
| Rate for Payer: BCBS POS |
$1,867.70
|
| Rate for Payer: BCBS Traditional |
$1,966.00
|
| Rate for Payer: CASH_PRICE |
$1,572.80
|
| Rate for Payer: CIGNA Commercial |
$1,867.70
|
| Rate for Payer: CIGNA Medicare |
$1,769.40
|
| Rate for Payer: HUMANA Commercial |
$1,769.40
|
| Rate for Payer: MEDICAID Medicaid |
$1,808.72
|
| Rate for Payer: MEDICARE Medicare |
$1,376.20
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$1,867.70
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$1,907.02
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$1,867.70
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$1,867.70
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$1,671.10
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$1,572.80
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$1,572.80
|
|
|
CT PELVIS WO CONTRAST
|
Facility
OP
|
$1,546.00
|
|
|
Service Code
|
CPT 72192 TC
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$1,082.20 |
| Max. Negotiated Rate |
$1,546.00 |
| Rate for Payer: AETNA Commercial |
$1,468.70
|
| Rate for Payer: AETNA Medicare |
$1,391.40
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$1,468.70
|
| Rate for Payer: BCBS Healthlink |
$1,391.40
|
| Rate for Payer: BCBS HMK CHIP |
$1,391.40
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$1,391.40
|
| Rate for Payer: BCBS POS |
$1,468.70
|
| Rate for Payer: BCBS Traditional |
$1,546.00
|
| Rate for Payer: CASH_PRICE |
$1,236.80
|
| Rate for Payer: CIGNA Commercial |
$1,468.70
|
| Rate for Payer: CIGNA Medicare |
$1,391.40
|
| Rate for Payer: HUMANA Commercial |
$1,391.40
|
| Rate for Payer: MEDICAID Medicaid |
$1,422.32
|
| Rate for Payer: MEDICARE Medicare |
$1,082.20
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$1,468.70
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$1,499.62
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$1,468.70
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$1,468.70
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$1,314.10
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$1,236.80
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$1,236.80
|
|
|
CT PELVIS WO CONTRAST
|
Facility
IP
|
$1,546.00
|
|
|
Service Code
|
CPT 72192 TC
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$1,082.20 |
| Max. Negotiated Rate |
$1,546.00 |
| Rate for Payer: AETNA Commercial |
$1,468.70
|
| Rate for Payer: AETNA Medicare |
$1,391.40
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$1,468.70
|
| Rate for Payer: BCBS Healthlink |
$1,391.40
|
| Rate for Payer: BCBS HMK CHIP |
$1,391.40
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$1,391.40
|
| Rate for Payer: BCBS POS |
$1,468.70
|
| Rate for Payer: BCBS Traditional |
$1,546.00
|
| Rate for Payer: CASH_PRICE |
$1,236.80
|
| Rate for Payer: CIGNA Commercial |
$1,468.70
|
| Rate for Payer: CIGNA Medicare |
$1,391.40
|
| Rate for Payer: HUMANA Commercial |
$1,391.40
|
| Rate for Payer: MEDICAID Medicaid |
$1,422.32
|
| Rate for Payer: MEDICARE Medicare |
$1,082.20
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$1,468.70
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$1,499.62
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$1,468.70
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$1,468.70
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$1,314.10
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$1,236.80
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$1,236.80
|
|
|
CT PELVIS W WO CONTRAST
|
Facility
OP
|
$2,222.00
|
|
|
Service Code
|
CPT 72194 TC
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$1,555.40 |
| Max. Negotiated Rate |
$2,222.00 |
| Rate for Payer: AETNA Commercial |
$2,110.90
|
| Rate for Payer: AETNA Medicare |
$1,999.80
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$2,110.90
|
| Rate for Payer: BCBS Healthlink |
$1,999.80
|
| Rate for Payer: BCBS HMK CHIP |
$1,999.80
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$1,999.80
|
| Rate for Payer: BCBS POS |
$2,110.90
|
| Rate for Payer: BCBS Traditional |
$2,222.00
|
| Rate for Payer: CASH_PRICE |
$1,777.60
|
| Rate for Payer: CIGNA Commercial |
$2,110.90
|
| Rate for Payer: CIGNA Medicare |
$1,999.80
|
| Rate for Payer: HUMANA Commercial |
$1,999.80
|
| Rate for Payer: MEDICAID Medicaid |
$2,044.24
|
| Rate for Payer: MEDICARE Medicare |
$1,555.40
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$2,110.90
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$2,155.34
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$2,110.90
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$2,110.90
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$1,888.70
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$1,777.60
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$1,777.60
|
|
|
CT PELVIS W WO CONTRAST
|
Facility
IP
|
$2,222.00
|
|
|
Service Code
|
CPT 72194 TC
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$1,555.40 |
| Max. Negotiated Rate |
$2,222.00 |
| Rate for Payer: BCBS HMK CHIP |
$1,999.80
|
| Rate for Payer: AETNA Commercial |
$2,110.90
|
| Rate for Payer: AETNA Medicare |
$1,999.80
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$2,110.90
|
| Rate for Payer: BCBS Healthlink |
$1,999.80
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$1,999.80
|
| Rate for Payer: BCBS POS |
$2,110.90
|
| Rate for Payer: BCBS Traditional |
$2,222.00
|
| Rate for Payer: CASH_PRICE |
$1,777.60
|
| Rate for Payer: CIGNA Commercial |
$2,110.90
|
| Rate for Payer: CIGNA Medicare |
$1,999.80
|
| Rate for Payer: HUMANA Commercial |
$1,999.80
|
| Rate for Payer: MEDICAID Medicaid |
$2,044.24
|
| Rate for Payer: MEDICARE Medicare |
$1,555.40
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$2,110.90
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$2,155.34
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$2,110.90
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$2,110.90
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$1,888.70
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$1,777.60
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$1,777.60
|
|
|
CT SINUS STUDY WO CONTRAST
|
Facility
OP
|
$1,436.00
|
|
|
Service Code
|
CPT 70486 TC
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$1,005.20 |
| Max. Negotiated Rate |
$1,436.00 |
| Rate for Payer: AETNA Commercial |
$1,364.20
|
| Rate for Payer: AETNA Medicare |
$1,292.40
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$1,364.20
|
| Rate for Payer: BCBS Healthlink |
$1,292.40
|
| Rate for Payer: BCBS HMK CHIP |
$1,292.40
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$1,292.40
|
| Rate for Payer: BCBS POS |
$1,364.20
|
| Rate for Payer: BCBS Traditional |
$1,436.00
|
| Rate for Payer: CASH_PRICE |
$1,148.80
|
| Rate for Payer: CIGNA Commercial |
$1,364.20
|
| Rate for Payer: CIGNA Medicare |
$1,292.40
|
| Rate for Payer: HUMANA Commercial |
$1,292.40
|
| Rate for Payer: MEDICAID Medicaid |
$1,321.12
|
| Rate for Payer: MEDICARE Medicare |
$1,005.20
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$1,364.20
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$1,392.92
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$1,364.20
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$1,364.20
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$1,220.60
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$1,148.80
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$1,148.80
|
|
|
CT SINUS STUDY WO CONTRAST
|
Facility
IP
|
$1,436.00
|
|
|
Service Code
|
CPT 70486 TC
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$1,005.20 |
| Max. Negotiated Rate |
$1,436.00 |
| Rate for Payer: BCBS HMK CHIP |
$1,292.40
|
| Rate for Payer: AETNA Commercial |
$1,364.20
|
| Rate for Payer: AETNA Medicare |
$1,292.40
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$1,364.20
|
| Rate for Payer: BCBS Healthlink |
$1,292.40
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$1,292.40
|
| Rate for Payer: BCBS POS |
$1,364.20
|
| Rate for Payer: BCBS Traditional |
$1,436.00
|
| Rate for Payer: CASH_PRICE |
$1,148.80
|
| Rate for Payer: CIGNA Commercial |
$1,364.20
|
| Rate for Payer: CIGNA Medicare |
$1,292.40
|
| Rate for Payer: HUMANA Commercial |
$1,292.40
|
| Rate for Payer: MEDICAID Medicaid |
$1,321.12
|
| Rate for Payer: MEDICARE Medicare |
$1,005.20
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$1,364.20
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$1,392.92
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$1,364.20
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$1,364.20
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$1,220.60
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$1,148.80
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$1,148.80
|
|
|
CT SOFT TISSUE NECK W CONTRAST
|
Facility
OP
|
$1,846.00
|
|
|
Service Code
|
CPT 70491 TC
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$1,292.20 |
| Max. Negotiated Rate |
$1,846.00 |
| Rate for Payer: AETNA Commercial |
$1,753.70
|
| Rate for Payer: AETNA Medicare |
$1,661.40
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$1,753.70
|
| Rate for Payer: BCBS Healthlink |
$1,661.40
|
| Rate for Payer: BCBS HMK CHIP |
$1,661.40
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$1,661.40
|
| Rate for Payer: BCBS POS |
$1,753.70
|
| Rate for Payer: BCBS Traditional |
$1,846.00
|
| Rate for Payer: CASH_PRICE |
$1,476.80
|
| Rate for Payer: CIGNA Commercial |
$1,753.70
|
| Rate for Payer: CIGNA Medicare |
$1,661.40
|
| Rate for Payer: HUMANA Commercial |
$1,661.40
|
| Rate for Payer: MEDICAID Medicaid |
$1,698.32
|
| Rate for Payer: MEDICARE Medicare |
$1,292.20
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$1,753.70
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$1,790.62
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$1,753.70
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$1,753.70
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$1,569.10
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$1,476.80
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$1,476.80
|
|
|
CT SOFT TISSUE NECK W CONTRAST
|
Facility
IP
|
$1,846.00
|
|
|
Service Code
|
CPT 70491 TC
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$1,292.20 |
| Max. Negotiated Rate |
$1,846.00 |
| Rate for Payer: AETNA Commercial |
$1,753.70
|
| Rate for Payer: AETNA Medicare |
$1,661.40
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$1,753.70
|
| Rate for Payer: BCBS Healthlink |
$1,661.40
|
| Rate for Payer: BCBS HMK CHIP |
$1,661.40
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$1,661.40
|
| Rate for Payer: BCBS POS |
$1,753.70
|
| Rate for Payer: BCBS Traditional |
$1,846.00
|
| Rate for Payer: CASH_PRICE |
$1,476.80
|
| Rate for Payer: CIGNA Commercial |
$1,753.70
|
| Rate for Payer: CIGNA Medicare |
$1,661.40
|
| Rate for Payer: HUMANA Commercial |
$1,661.40
|
| Rate for Payer: MEDICAID Medicaid |
$1,698.32
|
| Rate for Payer: MEDICARE Medicare |
$1,292.20
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$1,753.70
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$1,790.62
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$1,753.70
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$1,753.70
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$1,569.10
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$1,476.80
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$1,476.80
|
|
|
CT SOFT TISSUE NECK WO CONTRAST
|
Facility
OP
|
$1,452.00
|
|
|
Service Code
|
CPT 70490 TC
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$1,016.40 |
| Max. Negotiated Rate |
$1,452.00 |
| Rate for Payer: AETNA Commercial |
$1,379.40
|
| Rate for Payer: AETNA Medicare |
$1,306.80
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$1,379.40
|
| Rate for Payer: BCBS Healthlink |
$1,306.80
|
| Rate for Payer: BCBS HMK CHIP |
$1,306.80
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$1,306.80
|
| Rate for Payer: BCBS POS |
$1,379.40
|
| Rate for Payer: BCBS Traditional |
$1,452.00
|
| Rate for Payer: CASH_PRICE |
$1,161.60
|
| Rate for Payer: CIGNA Commercial |
$1,379.40
|
| Rate for Payer: CIGNA Medicare |
$1,306.80
|
| Rate for Payer: HUMANA Commercial |
$1,306.80
|
| Rate for Payer: MEDICAID Medicaid |
$1,335.84
|
| Rate for Payer: MEDICARE Medicare |
$1,016.40
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$1,379.40
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$1,408.44
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$1,379.40
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$1,379.40
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$1,234.20
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$1,161.60
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$1,161.60
|
|
|
CT SOFT TISSUE NECK WO CONTRAST
|
Facility
IP
|
$1,452.00
|
|
|
Service Code
|
CPT 70490 TC
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$1,016.40 |
| Max. Negotiated Rate |
$1,452.00 |
| Rate for Payer: AETNA Commercial |
$1,379.40
|
| Rate for Payer: AETNA Medicare |
$1,306.80
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$1,379.40
|
| Rate for Payer: BCBS Healthlink |
$1,306.80
|
| Rate for Payer: BCBS HMK CHIP |
$1,306.80
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$1,306.80
|
| Rate for Payer: BCBS POS |
$1,379.40
|
| Rate for Payer: BCBS Traditional |
$1,452.00
|
| Rate for Payer: CASH_PRICE |
$1,161.60
|
| Rate for Payer: CIGNA Commercial |
$1,379.40
|
| Rate for Payer: CIGNA Medicare |
$1,306.80
|
| Rate for Payer: HUMANA Commercial |
$1,306.80
|
| Rate for Payer: MEDICAID Medicaid |
$1,335.84
|
| Rate for Payer: MEDICARE Medicare |
$1,016.40
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$1,379.40
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$1,408.44
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$1,379.40
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$1,379.40
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$1,234.20
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$1,161.60
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$1,161.60
|
|
|
CT SOFT TISSUE NECK W WO CONTRAST
|
Facility
OP
|
$2,064.00
|
|
|
Service Code
|
CPT 70492 TC
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$1,444.80 |
| Max. Negotiated Rate |
$2,064.00 |
| Rate for Payer: AETNA Commercial |
$1,960.80
|
| Rate for Payer: AETNA Medicare |
$1,857.60
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$1,960.80
|
| Rate for Payer: BCBS Healthlink |
$1,857.60
|
| Rate for Payer: BCBS HMK CHIP |
$1,857.60
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$1,857.60
|
| Rate for Payer: BCBS POS |
$1,960.80
|
| Rate for Payer: BCBS Traditional |
$2,064.00
|
| Rate for Payer: CASH_PRICE |
$1,651.20
|
| Rate for Payer: CIGNA Commercial |
$1,960.80
|
| Rate for Payer: CIGNA Medicare |
$1,857.60
|
| Rate for Payer: HUMANA Commercial |
$1,857.60
|
| Rate for Payer: MEDICAID Medicaid |
$1,898.88
|
| Rate for Payer: MEDICARE Medicare |
$1,444.80
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$1,960.80
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$2,002.08
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$1,960.80
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$1,960.80
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$1,754.40
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$1,651.20
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$1,651.20
|
|
|
CT SOFT TISSUE NECK W WO CONTRAST
|
Facility
IP
|
$2,064.00
|
|
|
Service Code
|
CPT 70492 TC
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$1,444.80 |
| Max. Negotiated Rate |
$2,064.00 |
| Rate for Payer: BCBS HMK CHIP |
$1,857.60
|
| Rate for Payer: AETNA Commercial |
$1,960.80
|
| Rate for Payer: AETNA Medicare |
$1,857.60
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$1,960.80
|
| Rate for Payer: BCBS Healthlink |
$1,857.60
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$1,857.60
|
| Rate for Payer: BCBS POS |
$1,960.80
|
| Rate for Payer: BCBS Traditional |
$2,064.00
|
| Rate for Payer: CASH_PRICE |
$1,651.20
|
| Rate for Payer: CIGNA Commercial |
$1,960.80
|
| Rate for Payer: CIGNA Medicare |
$1,857.60
|
| Rate for Payer: HUMANA Commercial |
$1,857.60
|
| Rate for Payer: MEDICAID Medicaid |
$1,898.88
|
| Rate for Payer: MEDICARE Medicare |
$1,444.80
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$1,960.80
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$2,002.08
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$1,960.80
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$1,960.80
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$1,754.40
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$1,651.20
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$1,651.20
|
|
|
CT THORACIC SPINE W CONTRAST
|
Facility
OP
|
$2,003.00
|
|
|
Service Code
|
CPT 72129 TC
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$1,402.10 |
| Max. Negotiated Rate |
$2,003.00 |
| Rate for Payer: AETNA Commercial |
$1,902.85
|
| Rate for Payer: AETNA Medicare |
$1,802.70
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$1,902.85
|
| Rate for Payer: BCBS Healthlink |
$1,802.70
|
| Rate for Payer: BCBS HMK CHIP |
$1,802.70
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$1,802.70
|
| Rate for Payer: BCBS POS |
$1,902.85
|
| Rate for Payer: BCBS Traditional |
$2,003.00
|
| Rate for Payer: CASH_PRICE |
$1,602.40
|
| Rate for Payer: CIGNA Commercial |
$1,902.85
|
| Rate for Payer: CIGNA Medicare |
$1,802.70
|
| Rate for Payer: HUMANA Commercial |
$1,802.70
|
| Rate for Payer: MEDICAID Medicaid |
$1,842.76
|
| Rate for Payer: MEDICARE Medicare |
$1,402.10
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$1,902.85
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$1,942.91
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$1,902.85
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$1,902.85
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$1,702.55
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$1,602.40
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$1,602.40
|
|
|
CT THORACIC SPINE W CONTRAST
|
Facility
IP
|
$2,003.00
|
|
|
Service Code
|
CPT 72129 TC
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$1,402.10 |
| Max. Negotiated Rate |
$2,003.00 |
| Rate for Payer: BCBS HMK CHIP |
$1,802.70
|
| Rate for Payer: AETNA Commercial |
$1,902.85
|
| Rate for Payer: AETNA Medicare |
$1,802.70
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$1,902.85
|
| Rate for Payer: BCBS Healthlink |
$1,802.70
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$1,802.70
|
| Rate for Payer: BCBS POS |
$1,902.85
|
| Rate for Payer: BCBS Traditional |
$2,003.00
|
| Rate for Payer: CASH_PRICE |
$1,602.40
|
| Rate for Payer: CIGNA Commercial |
$1,902.85
|
| Rate for Payer: CIGNA Medicare |
$1,802.70
|
| Rate for Payer: HUMANA Commercial |
$1,802.70
|
| Rate for Payer: MEDICAID Medicaid |
$1,842.76
|
| Rate for Payer: MEDICARE Medicare |
$1,402.10
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$1,902.85
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$1,942.91
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$1,902.85
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$1,902.85
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$1,702.55
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$1,602.40
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$1,602.40
|
|
|
CT THORACIC SPINE WO CONTRAST
|
Facility
IP
|
$1,611.00
|
|
|
Service Code
|
CPT 72128 TC
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$1,127.70 |
| Max. Negotiated Rate |
$1,611.00 |
| Rate for Payer: BCBS HMK CHIP |
$1,449.90
|
| Rate for Payer: AETNA Commercial |
$1,530.45
|
| Rate for Payer: AETNA Medicare |
$1,449.90
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$1,530.45
|
| Rate for Payer: BCBS Healthlink |
$1,449.90
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$1,449.90
|
| Rate for Payer: BCBS POS |
$1,530.45
|
| Rate for Payer: BCBS Traditional |
$1,611.00
|
| Rate for Payer: CASH_PRICE |
$1,288.80
|
| Rate for Payer: CIGNA Commercial |
$1,530.45
|
| Rate for Payer: CIGNA Medicare |
$1,449.90
|
| Rate for Payer: HUMANA Commercial |
$1,449.90
|
| Rate for Payer: MEDICAID Medicaid |
$1,482.12
|
| Rate for Payer: MEDICARE Medicare |
$1,127.70
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$1,530.45
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$1,562.67
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$1,530.45
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$1,530.45
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$1,369.35
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$1,288.80
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$1,288.80
|
|
|
CT THORACIC SPINE WO CONTRAST
|
Facility
OP
|
$1,611.00
|
|
|
Service Code
|
CPT 72128 TC
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$1,127.70 |
| Max. Negotiated Rate |
$1,611.00 |
| Rate for Payer: AETNA Commercial |
$1,530.45
|
| Rate for Payer: AETNA Medicare |
$1,449.90
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$1,530.45
|
| Rate for Payer: BCBS Healthlink |
$1,449.90
|
| Rate for Payer: BCBS HMK CHIP |
$1,449.90
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$1,449.90
|
| Rate for Payer: BCBS POS |
$1,530.45
|
| Rate for Payer: BCBS Traditional |
$1,611.00
|
| Rate for Payer: CASH_PRICE |
$1,288.80
|
| Rate for Payer: CIGNA Commercial |
$1,530.45
|
| Rate for Payer: CIGNA Medicare |
$1,449.90
|
| Rate for Payer: HUMANA Commercial |
$1,449.90
|
| Rate for Payer: MEDICAID Medicaid |
$1,482.12
|
| Rate for Payer: MEDICARE Medicare |
$1,127.70
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$1,530.45
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$1,562.67
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$1,530.45
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$1,530.45
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$1,369.35
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$1,288.80
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$1,288.80
|
|
