|
LAB HSV CULTURE TYPE 1
|
Facility
|
IP
|
$80.00
|
|
|
Service Code
|
HCPCS 87274
|
| Hospital Charge Code |
4087274
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$56.00 |
| Max. Negotiated Rate |
$80.00 |
| Rate for Payer: Aetna Commercial |
$76.00
|
| Rate for Payer: Aetna Medicare |
$72.00
|
| Rate for Payer: BCBS MT CHIP |
$72.00
|
| Rate for Payer: BCBS MT Closed Plan Network |
$76.00
|
| Rate for Payer: BCBS MT HealthLink |
$72.00
|
| Rate for Payer: BCBS MT Medicare |
$72.00
|
| Rate for Payer: BCBS MT POS |
$76.00
|
| Rate for Payer: BCBS MT Traditional |
$80.00
|
| Rate for Payer: Cash Price |
$72.00
|
| Rate for Payer: Cigna Commercial |
$76.00
|
| Rate for Payer: Cigna Medicare |
$72.00
|
| Rate for Payer: Medicaid All Medicaid |
$73.60
|
| Rate for Payer: Medicare All Medicare |
$56.00
|
| Rate for Payer: Monida Allegiance |
$76.00
|
| Rate for Payer: Monida First Choice Health |
$77.60
|
| Rate for Payer: Monida Montana Health Co-op |
$76.00
|
| Rate for Payer: Monida PacificSource |
$76.00
|
|
|
LAB HSV CULTURE TYPE 2
|
Facility
|
IP
|
$80.00
|
|
|
Service Code
|
HCPCS 87273
|
| Hospital Charge Code |
4087273
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$56.00 |
| Max. Negotiated Rate |
$80.00 |
| Rate for Payer: Aetna Commercial |
$76.00
|
| Rate for Payer: Aetna Medicare |
$72.00
|
| Rate for Payer: BCBS MT CHIP |
$72.00
|
| Rate for Payer: BCBS MT Closed Plan Network |
$76.00
|
| Rate for Payer: BCBS MT HealthLink |
$72.00
|
| Rate for Payer: BCBS MT Medicare |
$72.00
|
| Rate for Payer: BCBS MT POS |
$76.00
|
| Rate for Payer: BCBS MT Traditional |
$80.00
|
| Rate for Payer: Cash Price |
$72.00
|
| Rate for Payer: Cigna Commercial |
$76.00
|
| Rate for Payer: Cigna Medicare |
$72.00
|
| Rate for Payer: Medicaid All Medicaid |
$73.60
|
| Rate for Payer: Medicare All Medicare |
$56.00
|
| Rate for Payer: Monida Allegiance |
$76.00
|
| Rate for Payer: Monida First Choice Health |
$77.60
|
| Rate for Payer: Monida Montana Health Co-op |
$76.00
|
| Rate for Payer: Monida PacificSource |
$76.00
|
|
|
LAB HSV CULTURE TYPE 2
|
Facility
|
OP
|
$80.00
|
|
|
Service Code
|
HCPCS 87273
|
| Hospital Charge Code |
4087273
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$56.00 |
| Max. Negotiated Rate |
$80.00 |
| Rate for Payer: Aetna Commercial |
$76.00
|
| Rate for Payer: Aetna Medicare |
$72.00
|
| Rate for Payer: BCBS MT CHIP |
$72.00
|
| Rate for Payer: BCBS MT Closed Plan Network |
$76.00
|
| Rate for Payer: BCBS MT HealthLink |
$72.00
|
| Rate for Payer: BCBS MT Medicare |
$72.00
|
| Rate for Payer: BCBS MT POS |
$76.00
|
| Rate for Payer: BCBS MT Traditional |
$80.00
|
| Rate for Payer: Cash Price |
$72.00
|
| Rate for Payer: Cigna Commercial |
$76.00
|
| Rate for Payer: Cigna Medicare |
$72.00
|
| Rate for Payer: Medicaid All Medicaid |
$73.60
|
| Rate for Payer: Medicare All Medicare |
$56.00
|
| Rate for Payer: Monida Allegiance |
$76.00
|
| Rate for Payer: Monida First Choice Health |
$77.60
|
| Rate for Payer: Monida Montana Health Co-op |
$76.00
|
| Rate for Payer: Monida PacificSource |
$76.00
|
|
|
LAB HSV IG M
|
Facility
|
IP
|
$66.00
|
|
|
Service Code
|
HCPCS 86694
|
| Hospital Charge Code |
4086694
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$46.20 |
| Max. Negotiated Rate |
$66.00 |
| Rate for Payer: Aetna Commercial |
$62.70
|
| Rate for Payer: Aetna Medicare |
$59.40
|
| Rate for Payer: BCBS MT CHIP |
$59.40
|
| Rate for Payer: BCBS MT Closed Plan Network |
$62.70
|
| Rate for Payer: BCBS MT HealthLink |
$59.40
|
| Rate for Payer: BCBS MT Medicare |
$59.40
|
| Rate for Payer: BCBS MT POS |
$62.70
|
| Rate for Payer: BCBS MT Traditional |
$66.00
|
| Rate for Payer: Cash Price |
$59.40
|
| Rate for Payer: Cigna Commercial |
$62.70
|
| Rate for Payer: Cigna Medicare |
$59.40
|
| Rate for Payer: Medicaid All Medicaid |
$60.72
|
| Rate for Payer: Medicare All Medicare |
$46.20
|
| Rate for Payer: Monida Allegiance |
$62.70
|
| Rate for Payer: Monida First Choice Health |
$64.02
|
| Rate for Payer: Monida Montana Health Co-op |
$62.70
|
| Rate for Payer: Monida PacificSource |
$62.70
|
|
|
LAB HSV IG M
|
Facility
|
OP
|
$66.00
|
|
|
Service Code
|
HCPCS 86694
|
| Hospital Charge Code |
4086694
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$46.20 |
| Max. Negotiated Rate |
$66.00 |
| Rate for Payer: Aetna Commercial |
$62.70
|
| Rate for Payer: Aetna Medicare |
$59.40
|
| Rate for Payer: BCBS MT CHIP |
$59.40
|
| Rate for Payer: BCBS MT Closed Plan Network |
$62.70
|
| Rate for Payer: BCBS MT HealthLink |
$59.40
|
| Rate for Payer: BCBS MT Medicare |
$59.40
|
| Rate for Payer: BCBS MT POS |
$62.70
|
| Rate for Payer: BCBS MT Traditional |
$66.00
|
| Rate for Payer: Cash Price |
$59.40
|
| Rate for Payer: Cigna Commercial |
$62.70
|
| Rate for Payer: Cigna Medicare |
$59.40
|
| Rate for Payer: Medicaid All Medicaid |
$60.72
|
| Rate for Payer: Medicare All Medicare |
$46.20
|
| Rate for Payer: Monida Allegiance |
$62.70
|
| Rate for Payer: Monida First Choice Health |
$64.02
|
| Rate for Payer: Monida Montana Health Co-op |
$62.70
|
| Rate for Payer: Monida PacificSource |
$62.70
|
|
|
LAB IGF PROTEIN
|
Facility
|
IP
|
$203.00
|
|
|
Service Code
|
HCPCS 83519
|
| Hospital Charge Code |
4083519
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$142.10 |
| Max. Negotiated Rate |
$203.00 |
| Rate for Payer: Aetna Commercial |
$192.85
|
| Rate for Payer: Aetna Medicare |
$182.70
|
| Rate for Payer: BCBS MT CHIP |
$182.70
|
| Rate for Payer: BCBS MT Closed Plan Network |
$192.85
|
| Rate for Payer: BCBS MT HealthLink |
$182.70
|
| Rate for Payer: BCBS MT Medicare |
$182.70
|
| Rate for Payer: BCBS MT POS |
$192.85
|
| Rate for Payer: BCBS MT Traditional |
$203.00
|
| Rate for Payer: Cash Price |
$182.70
|
| Rate for Payer: Cigna Commercial |
$192.85
|
| Rate for Payer: Cigna Medicare |
$182.70
|
| Rate for Payer: Medicaid All Medicaid |
$186.76
|
| Rate for Payer: Medicare All Medicare |
$142.10
|
| Rate for Payer: Monida Allegiance |
$192.85
|
| Rate for Payer: Monida First Choice Health |
$196.91
|
| Rate for Payer: Monida Montana Health Co-op |
$192.85
|
| Rate for Payer: Monida PacificSource |
$192.85
|
|
|
LAB IGF PROTEIN
|
Facility
|
OP
|
$203.00
|
|
|
Service Code
|
HCPCS 83519
|
| Hospital Charge Code |
4083519
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$142.10 |
| Max. Negotiated Rate |
$203.00 |
| Rate for Payer: Aetna Commercial |
$192.85
|
| Rate for Payer: Aetna Medicare |
$182.70
|
| Rate for Payer: BCBS MT CHIP |
$182.70
|
| Rate for Payer: BCBS MT Closed Plan Network |
$192.85
|
| Rate for Payer: BCBS MT HealthLink |
$182.70
|
| Rate for Payer: BCBS MT Medicare |
$182.70
|
| Rate for Payer: BCBS MT POS |
$192.85
|
| Rate for Payer: BCBS MT Traditional |
$203.00
|
| Rate for Payer: Cash Price |
$182.70
|
| Rate for Payer: Cigna Commercial |
$192.85
|
| Rate for Payer: Cigna Medicare |
$182.70
|
| Rate for Payer: Medicaid All Medicaid |
$186.76
|
| Rate for Payer: Medicare All Medicare |
$142.10
|
| Rate for Payer: Monida Allegiance |
$192.85
|
| Rate for Payer: Monida First Choice Health |
$196.91
|
| Rate for Payer: Monida Montana Health Co-op |
$192.85
|
| Rate for Payer: Monida PacificSource |
$192.85
|
|
|
LAB IMMUNOCHEM QUAL FECAL SCREEN
|
Facility
|
IP
|
$73.00
|
|
|
Service Code
|
HCPCS 82274
|
| Hospital Charge Code |
4082274
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$51.10 |
| Max. Negotiated Rate |
$73.00 |
| Rate for Payer: Aetna Commercial |
$69.35
|
| Rate for Payer: Aetna Medicare |
$65.70
|
| Rate for Payer: BCBS MT CHIP |
$65.70
|
| Rate for Payer: BCBS MT Closed Plan Network |
$69.35
|
| Rate for Payer: BCBS MT HealthLink |
$65.70
|
| Rate for Payer: BCBS MT Medicare |
$65.70
|
| Rate for Payer: BCBS MT POS |
$69.35
|
| Rate for Payer: BCBS MT Traditional |
$73.00
|
| Rate for Payer: Cash Price |
$65.70
|
| Rate for Payer: Cigna Commercial |
$69.35
|
| Rate for Payer: Cigna Medicare |
$65.70
|
| Rate for Payer: Medicaid All Medicaid |
$67.16
|
| Rate for Payer: Medicare All Medicare |
$51.10
|
| Rate for Payer: Monida Allegiance |
$69.35
|
| Rate for Payer: Monida First Choice Health |
$70.81
|
| Rate for Payer: Monida Montana Health Co-op |
$69.35
|
| Rate for Payer: Monida PacificSource |
$69.35
|
|
|
LAB IMMUNOCHEM QUAL FECAL SCREEN
|
Facility
|
OP
|
$73.00
|
|
|
Service Code
|
HCPCS 82274
|
| Hospital Charge Code |
4082274
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$51.10 |
| Max. Negotiated Rate |
$73.00 |
| Rate for Payer: Aetna Commercial |
$69.35
|
| Rate for Payer: Aetna Medicare |
$65.70
|
| Rate for Payer: BCBS MT CHIP |
$65.70
|
| Rate for Payer: BCBS MT Closed Plan Network |
$69.35
|
| Rate for Payer: BCBS MT HealthLink |
$65.70
|
| Rate for Payer: BCBS MT Medicare |
$65.70
|
| Rate for Payer: BCBS MT POS |
$69.35
|
| Rate for Payer: BCBS MT Traditional |
$73.00
|
| Rate for Payer: Cash Price |
$65.70
|
| Rate for Payer: Cigna Commercial |
$69.35
|
| Rate for Payer: Cigna Medicare |
$65.70
|
| Rate for Payer: Medicaid All Medicaid |
$67.16
|
| Rate for Payer: Medicare All Medicare |
$51.10
|
| Rate for Payer: Monida Allegiance |
$69.35
|
| Rate for Payer: Monida First Choice Health |
$70.81
|
| Rate for Payer: Monida Montana Health Co-op |
$69.35
|
| Rate for Payer: Monida PacificSource |
$69.35
|
|
|
LAB INFLUENZA A&B
|
Facility
|
IP
|
$104.00
|
|
|
Service Code
|
HCPCS 87400 91
|
| Hospital Charge Code |
4074001
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$72.80 |
| Max. Negotiated Rate |
$104.00 |
| Rate for Payer: Aetna Commercial |
$98.80
|
| Rate for Payer: Aetna Medicare |
$93.60
|
| Rate for Payer: BCBS MT CHIP |
$93.60
|
| Rate for Payer: BCBS MT Closed Plan Network |
$98.80
|
| Rate for Payer: BCBS MT HealthLink |
$93.60
|
| Rate for Payer: BCBS MT Medicare |
$93.60
|
| Rate for Payer: BCBS MT POS |
$98.80
|
| Rate for Payer: BCBS MT Traditional |
$104.00
|
| Rate for Payer: Cash Price |
$93.60
|
| Rate for Payer: Cigna Commercial |
$98.80
|
| Rate for Payer: Cigna Medicare |
$93.60
|
| Rate for Payer: Medicaid All Medicaid |
$95.68
|
| Rate for Payer: Medicare All Medicare |
$72.80
|
| Rate for Payer: Monida Allegiance |
$98.80
|
| Rate for Payer: Monida First Choice Health |
$100.88
|
| Rate for Payer: Monida Montana Health Co-op |
$98.80
|
| Rate for Payer: Monida PacificSource |
$98.80
|
|
|
LAB INFLUENZA A&B
|
Facility
|
OP
|
$104.00
|
|
|
Service Code
|
HCPCS 87400
|
| Hospital Charge Code |
4087400
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$72.80 |
| Max. Negotiated Rate |
$104.00 |
| Rate for Payer: Aetna Commercial |
$98.80
|
| Rate for Payer: Aetna Medicare |
$93.60
|
| Rate for Payer: BCBS MT CHIP |
$93.60
|
| Rate for Payer: BCBS MT Closed Plan Network |
$98.80
|
| Rate for Payer: BCBS MT HealthLink |
$93.60
|
| Rate for Payer: BCBS MT Medicare |
$93.60
|
| Rate for Payer: BCBS MT POS |
$98.80
|
| Rate for Payer: BCBS MT Traditional |
$104.00
|
| Rate for Payer: Cash Price |
$93.60
|
| Rate for Payer: Cigna Commercial |
$98.80
|
| Rate for Payer: Cigna Medicare |
$93.60
|
| Rate for Payer: Medicaid All Medicaid |
$95.68
|
| Rate for Payer: Medicare All Medicare |
$72.80
|
| Rate for Payer: Monida Allegiance |
$98.80
|
| Rate for Payer: Monida First Choice Health |
$100.88
|
| Rate for Payer: Monida Montana Health Co-op |
$98.80
|
| Rate for Payer: Monida PacificSource |
$98.80
|
|
|
LAB INFLUENZA A&B
|
Facility
|
OP
|
$104.00
|
|
|
Service Code
|
HCPCS 87400 91
|
| Hospital Charge Code |
4074001
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$72.80 |
| Max. Negotiated Rate |
$104.00 |
| Rate for Payer: Aetna Commercial |
$98.80
|
| Rate for Payer: Aetna Medicare |
$93.60
|
| Rate for Payer: BCBS MT CHIP |
$93.60
|
| Rate for Payer: BCBS MT Closed Plan Network |
$98.80
|
| Rate for Payer: BCBS MT HealthLink |
$93.60
|
| Rate for Payer: BCBS MT Medicare |
$93.60
|
| Rate for Payer: BCBS MT POS |
$98.80
|
| Rate for Payer: BCBS MT Traditional |
$104.00
|
| Rate for Payer: Cash Price |
$93.60
|
| Rate for Payer: Cigna Commercial |
$98.80
|
| Rate for Payer: Cigna Medicare |
$93.60
|
| Rate for Payer: Medicaid All Medicaid |
$95.68
|
| Rate for Payer: Medicare All Medicare |
$72.80
|
| Rate for Payer: Monida Allegiance |
$98.80
|
| Rate for Payer: Monida First Choice Health |
$100.88
|
| Rate for Payer: Monida Montana Health Co-op |
$98.80
|
| Rate for Payer: Monida PacificSource |
$98.80
|
|
|
LAB INFLUENZA A&B
|
Facility
|
IP
|
$104.00
|
|
|
Service Code
|
HCPCS 87400
|
| Hospital Charge Code |
4087400
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$72.80 |
| Max. Negotiated Rate |
$104.00 |
| Rate for Payer: Aetna Commercial |
$98.80
|
| Rate for Payer: Aetna Medicare |
$93.60
|
| Rate for Payer: BCBS MT CHIP |
$93.60
|
| Rate for Payer: BCBS MT Closed Plan Network |
$98.80
|
| Rate for Payer: BCBS MT HealthLink |
$93.60
|
| Rate for Payer: BCBS MT Medicare |
$93.60
|
| Rate for Payer: BCBS MT POS |
$98.80
|
| Rate for Payer: BCBS MT Traditional |
$104.00
|
| Rate for Payer: Cash Price |
$93.60
|
| Rate for Payer: Cigna Commercial |
$98.80
|
| Rate for Payer: Cigna Medicare |
$93.60
|
| Rate for Payer: Medicaid All Medicaid |
$95.68
|
| Rate for Payer: Medicare All Medicare |
$72.80
|
| Rate for Payer: Monida Allegiance |
$98.80
|
| Rate for Payer: Monida First Choice Health |
$100.88
|
| Rate for Payer: Monida Montana Health Co-op |
$98.80
|
| Rate for Payer: Monida PacificSource |
$98.80
|
|
|
LAB INFLUENZA/RAPID
|
Facility
|
IP
|
$83.00
|
|
|
Service Code
|
HCPCS 86710
|
| Hospital Charge Code |
4086710
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$58.10 |
| Max. Negotiated Rate |
$83.00 |
| Rate for Payer: Aetna Commercial |
$78.85
|
| Rate for Payer: Aetna Medicare |
$74.70
|
| Rate for Payer: BCBS MT CHIP |
$74.70
|
| Rate for Payer: BCBS MT Closed Plan Network |
$78.85
|
| Rate for Payer: BCBS MT HealthLink |
$74.70
|
| Rate for Payer: BCBS MT Medicare |
$74.70
|
| Rate for Payer: BCBS MT POS |
$78.85
|
| Rate for Payer: BCBS MT Traditional |
$83.00
|
| Rate for Payer: Cash Price |
$74.70
|
| Rate for Payer: Cigna Commercial |
$78.85
|
| Rate for Payer: Cigna Medicare |
$74.70
|
| Rate for Payer: Medicaid All Medicaid |
$76.36
|
| Rate for Payer: Medicare All Medicare |
$58.10
|
| Rate for Payer: Monida Allegiance |
$78.85
|
| Rate for Payer: Monida First Choice Health |
$80.51
|
| Rate for Payer: Monida Montana Health Co-op |
$78.85
|
| Rate for Payer: Monida PacificSource |
$78.85
|
|
|
LAB INFLUENZA/RAPID
|
Facility
|
OP
|
$83.00
|
|
|
Service Code
|
HCPCS 86710
|
| Hospital Charge Code |
4086710
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$58.10 |
| Max. Negotiated Rate |
$83.00 |
| Rate for Payer: Aetna Commercial |
$78.85
|
| Rate for Payer: Aetna Medicare |
$74.70
|
| Rate for Payer: BCBS MT CHIP |
$74.70
|
| Rate for Payer: BCBS MT Closed Plan Network |
$78.85
|
| Rate for Payer: BCBS MT HealthLink |
$74.70
|
| Rate for Payer: BCBS MT Medicare |
$74.70
|
| Rate for Payer: BCBS MT POS |
$78.85
|
| Rate for Payer: BCBS MT Traditional |
$83.00
|
| Rate for Payer: Cash Price |
$74.70
|
| Rate for Payer: Cigna Commercial |
$78.85
|
| Rate for Payer: Cigna Medicare |
$74.70
|
| Rate for Payer: Medicaid All Medicaid |
$76.36
|
| Rate for Payer: Medicare All Medicare |
$58.10
|
| Rate for Payer: Monida Allegiance |
$78.85
|
| Rate for Payer: Monida First Choice Health |
$80.51
|
| Rate for Payer: Monida Montana Health Co-op |
$78.85
|
| Rate for Payer: Monida PacificSource |
$78.85
|
|
|
LAB INSULIN AB
|
Facility
|
IP
|
$140.00
|
|
|
Service Code
|
HCPCS 86337
|
| Hospital Charge Code |
4086337
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$98.00 |
| Max. Negotiated Rate |
$140.00 |
| Rate for Payer: Aetna Commercial |
$133.00
|
| Rate for Payer: Aetna Medicare |
$126.00
|
| Rate for Payer: BCBS MT CHIP |
$126.00
|
| Rate for Payer: BCBS MT Closed Plan Network |
$133.00
|
| Rate for Payer: BCBS MT HealthLink |
$126.00
|
| Rate for Payer: BCBS MT Medicare |
$126.00
|
| Rate for Payer: BCBS MT POS |
$133.00
|
| Rate for Payer: BCBS MT Traditional |
$140.00
|
| Rate for Payer: Cash Price |
$126.00
|
| Rate for Payer: Cigna Commercial |
$133.00
|
| Rate for Payer: Cigna Medicare |
$126.00
|
| Rate for Payer: Medicaid All Medicaid |
$128.80
|
| Rate for Payer: Medicare All Medicare |
$98.00
|
| Rate for Payer: Monida Allegiance |
$133.00
|
| Rate for Payer: Monida First Choice Health |
$135.80
|
| Rate for Payer: Monida Montana Health Co-op |
$133.00
|
| Rate for Payer: Monida PacificSource |
$133.00
|
|
|
LAB INSULIN AB
|
Facility
|
OP
|
$140.00
|
|
|
Service Code
|
HCPCS 86337
|
| Hospital Charge Code |
4086337
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$98.00 |
| Max. Negotiated Rate |
$140.00 |
| Rate for Payer: Aetna Commercial |
$133.00
|
| Rate for Payer: Aetna Medicare |
$126.00
|
| Rate for Payer: BCBS MT CHIP |
$126.00
|
| Rate for Payer: BCBS MT Closed Plan Network |
$133.00
|
| Rate for Payer: BCBS MT HealthLink |
$126.00
|
| Rate for Payer: BCBS MT Medicare |
$126.00
|
| Rate for Payer: BCBS MT POS |
$133.00
|
| Rate for Payer: BCBS MT Traditional |
$140.00
|
| Rate for Payer: Cash Price |
$126.00
|
| Rate for Payer: Cigna Commercial |
$133.00
|
| Rate for Payer: Cigna Medicare |
$126.00
|
| Rate for Payer: Medicaid All Medicaid |
$128.80
|
| Rate for Payer: Medicare All Medicare |
$98.00
|
| Rate for Payer: Monida Allegiance |
$133.00
|
| Rate for Payer: Monida First Choice Health |
$135.80
|
| Rate for Payer: Monida Montana Health Co-op |
$133.00
|
| Rate for Payer: Monida PacificSource |
$133.00
|
|
|
LAB INSURANCE COLLECTION & HANDLING
|
Facility
|
IP
|
$48.00
|
|
|
Service Code
|
HCPCS 99001
|
| Hospital Charge Code |
4099999
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$33.60 |
| Max. Negotiated Rate |
$48.00 |
| Rate for Payer: Aetna Commercial |
$45.60
|
| Rate for Payer: Aetna Medicare |
$43.20
|
| Rate for Payer: BCBS MT CHIP |
$43.20
|
| Rate for Payer: BCBS MT Closed Plan Network |
$45.60
|
| Rate for Payer: BCBS MT HealthLink |
$43.20
|
| Rate for Payer: BCBS MT Medicare |
$43.20
|
| Rate for Payer: BCBS MT POS |
$45.60
|
| Rate for Payer: BCBS MT Traditional |
$48.00
|
| Rate for Payer: Cash Price |
$43.20
|
| Rate for Payer: Cigna Commercial |
$45.60
|
| Rate for Payer: Cigna Medicare |
$43.20
|
| Rate for Payer: Medicaid All Medicaid |
$44.16
|
| Rate for Payer: Medicare All Medicare |
$33.60
|
| Rate for Payer: Monida Allegiance |
$45.60
|
| Rate for Payer: Monida First Choice Health |
$46.56
|
| Rate for Payer: Monida Montana Health Co-op |
$45.60
|
| Rate for Payer: Monida PacificSource |
$45.60
|
|
|
LAB INSURANCE COLLECTION & HANDLING
|
Facility
|
OP
|
$48.00
|
|
|
Service Code
|
HCPCS 99001
|
| Hospital Charge Code |
4099999
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$33.60 |
| Max. Negotiated Rate |
$48.00 |
| Rate for Payer: Aetna Commercial |
$45.60
|
| Rate for Payer: Aetna Medicare |
$43.20
|
| Rate for Payer: BCBS MT CHIP |
$43.20
|
| Rate for Payer: BCBS MT Closed Plan Network |
$45.60
|
| Rate for Payer: BCBS MT HealthLink |
$43.20
|
| Rate for Payer: BCBS MT Medicare |
$43.20
|
| Rate for Payer: BCBS MT POS |
$45.60
|
| Rate for Payer: BCBS MT Traditional |
$48.00
|
| Rate for Payer: Cash Price |
$43.20
|
| Rate for Payer: Cigna Commercial |
$45.60
|
| Rate for Payer: Cigna Medicare |
$43.20
|
| Rate for Payer: Medicaid All Medicaid |
$44.16
|
| Rate for Payer: Medicare All Medicare |
$33.60
|
| Rate for Payer: Monida Allegiance |
$45.60
|
| Rate for Payer: Monida First Choice Health |
$46.56
|
| Rate for Payer: Monida Montana Health Co-op |
$45.60
|
| Rate for Payer: Monida PacificSource |
$45.60
|
|
|
LAB ISLET CELL AB SCREEN
|
Facility
|
OP
|
$120.00
|
|
|
Service Code
|
HCPCS 86341
|
| Hospital Charge Code |
4086341
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$84.00 |
| Max. Negotiated Rate |
$120.00 |
| Rate for Payer: Aetna Commercial |
$114.00
|
| Rate for Payer: Aetna Medicare |
$108.00
|
| Rate for Payer: BCBS MT CHIP |
$108.00
|
| Rate for Payer: BCBS MT Closed Plan Network |
$114.00
|
| Rate for Payer: BCBS MT HealthLink |
$108.00
|
| Rate for Payer: BCBS MT Medicare |
$108.00
|
| Rate for Payer: BCBS MT POS |
$114.00
|
| Rate for Payer: BCBS MT Traditional |
$120.00
|
| Rate for Payer: Cash Price |
$108.00
|
| Rate for Payer: Cigna Commercial |
$114.00
|
| Rate for Payer: Cigna Medicare |
$108.00
|
| Rate for Payer: Medicaid All Medicaid |
$110.40
|
| Rate for Payer: Medicare All Medicare |
$84.00
|
| Rate for Payer: Monida Allegiance |
$114.00
|
| Rate for Payer: Monida First Choice Health |
$116.40
|
| Rate for Payer: Monida Montana Health Co-op |
$114.00
|
| Rate for Payer: Monida PacificSource |
$114.00
|
|
|
LAB ISLET CELL AB SCREEN
|
Facility
|
IP
|
$120.00
|
|
|
Service Code
|
HCPCS 86341
|
| Hospital Charge Code |
4086341
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$84.00 |
| Max. Negotiated Rate |
$120.00 |
| Rate for Payer: Aetna Commercial |
$114.00
|
| Rate for Payer: Aetna Medicare |
$108.00
|
| Rate for Payer: BCBS MT CHIP |
$108.00
|
| Rate for Payer: BCBS MT Closed Plan Network |
$114.00
|
| Rate for Payer: BCBS MT HealthLink |
$108.00
|
| Rate for Payer: BCBS MT Medicare |
$108.00
|
| Rate for Payer: BCBS MT POS |
$114.00
|
| Rate for Payer: BCBS MT Traditional |
$120.00
|
| Rate for Payer: Cash Price |
$108.00
|
| Rate for Payer: Cigna Commercial |
$114.00
|
| Rate for Payer: Cigna Medicare |
$108.00
|
| Rate for Payer: Medicaid All Medicaid |
$110.40
|
| Rate for Payer: Medicare All Medicare |
$84.00
|
| Rate for Payer: Monida Allegiance |
$114.00
|
| Rate for Payer: Monida First Choice Health |
$116.40
|
| Rate for Payer: Monida Montana Health Co-op |
$114.00
|
| Rate for Payer: Monida PacificSource |
$114.00
|
|
|
LAB JCV ANTIBODY
|
Facility
|
OP
|
$208.00
|
|
|
Service Code
|
HCPCS 86711
|
| Hospital Charge Code |
4086711
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$145.60 |
| Max. Negotiated Rate |
$208.00 |
| Rate for Payer: Aetna Commercial |
$197.60
|
| Rate for Payer: Aetna Medicare |
$187.20
|
| Rate for Payer: BCBS MT CHIP |
$187.20
|
| Rate for Payer: BCBS MT Closed Plan Network |
$197.60
|
| Rate for Payer: BCBS MT HealthLink |
$187.20
|
| Rate for Payer: BCBS MT Medicare |
$187.20
|
| Rate for Payer: BCBS MT POS |
$197.60
|
| Rate for Payer: BCBS MT Traditional |
$208.00
|
| Rate for Payer: Cash Price |
$187.20
|
| Rate for Payer: Cigna Commercial |
$197.60
|
| Rate for Payer: Cigna Medicare |
$187.20
|
| Rate for Payer: Medicaid All Medicaid |
$191.36
|
| Rate for Payer: Medicare All Medicare |
$145.60
|
| Rate for Payer: Monida Allegiance |
$197.60
|
| Rate for Payer: Monida First Choice Health |
$201.76
|
| Rate for Payer: Monida Montana Health Co-op |
$197.60
|
| Rate for Payer: Monida PacificSource |
$197.60
|
|
|
LAB JCV ANTIBODY
|
Facility
|
IP
|
$208.00
|
|
|
Service Code
|
HCPCS 86711
|
| Hospital Charge Code |
4086711
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$145.60 |
| Max. Negotiated Rate |
$208.00 |
| Rate for Payer: Aetna Commercial |
$197.60
|
| Rate for Payer: Aetna Medicare |
$187.20
|
| Rate for Payer: BCBS MT CHIP |
$187.20
|
| Rate for Payer: BCBS MT Closed Plan Network |
$197.60
|
| Rate for Payer: BCBS MT HealthLink |
$187.20
|
| Rate for Payer: BCBS MT Medicare |
$187.20
|
| Rate for Payer: BCBS MT POS |
$197.60
|
| Rate for Payer: BCBS MT Traditional |
$208.00
|
| Rate for Payer: Cash Price |
$187.20
|
| Rate for Payer: Cigna Commercial |
$197.60
|
| Rate for Payer: Cigna Medicare |
$187.20
|
| Rate for Payer: Medicaid All Medicaid |
$191.36
|
| Rate for Payer: Medicare All Medicare |
$145.60
|
| Rate for Payer: Monida Allegiance |
$197.60
|
| Rate for Payer: Monida First Choice Health |
$201.76
|
| Rate for Payer: Monida Montana Health Co-op |
$197.60
|
| Rate for Payer: Monida PacificSource |
$197.60
|
|
|
LAB LACTOFERRIN, FECAL, QUALITATIVE
|
Facility
|
IP
|
$114.00
|
|
|
Service Code
|
HCPCS 83630
|
| Hospital Charge Code |
4083630
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$79.80 |
| Max. Negotiated Rate |
$114.00 |
| Rate for Payer: Aetna Commercial |
$108.30
|
| Rate for Payer: Aetna Medicare |
$102.60
|
| Rate for Payer: BCBS MT CHIP |
$102.60
|
| Rate for Payer: BCBS MT Closed Plan Network |
$108.30
|
| Rate for Payer: BCBS MT HealthLink |
$102.60
|
| Rate for Payer: BCBS MT Medicare |
$102.60
|
| Rate for Payer: BCBS MT POS |
$108.30
|
| Rate for Payer: BCBS MT Traditional |
$114.00
|
| Rate for Payer: Cash Price |
$102.60
|
| Rate for Payer: Cigna Commercial |
$108.30
|
| Rate for Payer: Cigna Medicare |
$102.60
|
| Rate for Payer: Medicaid All Medicaid |
$104.88
|
| Rate for Payer: Medicare All Medicare |
$79.80
|
| Rate for Payer: Monida Allegiance |
$108.30
|
| Rate for Payer: Monida First Choice Health |
$110.58
|
| Rate for Payer: Monida Montana Health Co-op |
$108.30
|
| Rate for Payer: Monida PacificSource |
$108.30
|
|
|
LAB LACTOFERRIN, FECAL, QUALITATIVE
|
Facility
|
OP
|
$114.00
|
|
|
Service Code
|
HCPCS 83630
|
| Hospital Charge Code |
4083630
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$79.80 |
| Max. Negotiated Rate |
$114.00 |
| Rate for Payer: Aetna Commercial |
$108.30
|
| Rate for Payer: Aetna Medicare |
$102.60
|
| Rate for Payer: BCBS MT CHIP |
$102.60
|
| Rate for Payer: BCBS MT Closed Plan Network |
$108.30
|
| Rate for Payer: BCBS MT HealthLink |
$102.60
|
| Rate for Payer: BCBS MT Medicare |
$102.60
|
| Rate for Payer: BCBS MT POS |
$108.30
|
| Rate for Payer: BCBS MT Traditional |
$114.00
|
| Rate for Payer: Cash Price |
$102.60
|
| Rate for Payer: Cigna Commercial |
$108.30
|
| Rate for Payer: Cigna Medicare |
$102.60
|
| Rate for Payer: Medicaid All Medicaid |
$104.88
|
| Rate for Payer: Medicare All Medicare |
$79.80
|
| Rate for Payer: Monida Allegiance |
$108.30
|
| Rate for Payer: Monida First Choice Health |
$110.58
|
| Rate for Payer: Monida Montana Health Co-op |
$108.30
|
| Rate for Payer: Monida PacificSource |
$108.30
|
|
