|
MAGNESIUM
|
Facility
|
IP
|
$95.00
|
|
|
Service Code
|
HCPCS 83735
|
| Hospital Charge Code |
4083735
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$66.50 |
| Max. Negotiated Rate |
$95.00 |
| Rate for Payer: Aetna Commercial |
$90.25
|
| Rate for Payer: Aetna Medicare |
$85.50
|
| Rate for Payer: BCBS MT CHIP |
$85.50
|
| Rate for Payer: BCBS MT Closed Plan Network |
$90.25
|
| Rate for Payer: BCBS MT HealthLink |
$85.50
|
| Rate for Payer: BCBS MT Medicare |
$85.50
|
| Rate for Payer: BCBS MT POS |
$90.25
|
| Rate for Payer: BCBS MT Traditional |
$95.00
|
| Rate for Payer: Cash Price |
$85.50
|
| Rate for Payer: Cigna Commercial |
$90.25
|
| Rate for Payer: Cigna Medicare |
$85.50
|
| Rate for Payer: Medicaid All Medicaid |
$87.40
|
| Rate for Payer: Medicare All Medicare |
$66.50
|
| Rate for Payer: Monida Allegiance |
$90.25
|
| Rate for Payer: Monida First Choice Health |
$92.15
|
| Rate for Payer: Monida Montana Health Co-op |
$90.25
|
| Rate for Payer: Monida PacificSource |
$90.25
|
|
|
MAGNESIUM
|
Facility
|
OP
|
$95.00
|
|
|
Service Code
|
HCPCS 83735
|
| Hospital Charge Code |
4083735
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$66.50 |
| Max. Negotiated Rate |
$95.00 |
| Rate for Payer: Aetna Commercial |
$90.25
|
| Rate for Payer: Aetna Medicare |
$85.50
|
| Rate for Payer: BCBS MT CHIP |
$85.50
|
| Rate for Payer: BCBS MT Closed Plan Network |
$90.25
|
| Rate for Payer: BCBS MT HealthLink |
$85.50
|
| Rate for Payer: BCBS MT Medicare |
$85.50
|
| Rate for Payer: BCBS MT POS |
$90.25
|
| Rate for Payer: BCBS MT Traditional |
$95.00
|
| Rate for Payer: Cash Price |
$85.50
|
| Rate for Payer: Cigna Commercial |
$90.25
|
| Rate for Payer: Cigna Medicare |
$85.50
|
| Rate for Payer: Medicaid All Medicaid |
$87.40
|
| Rate for Payer: Medicare All Medicare |
$66.50
|
| Rate for Payer: Monida Allegiance |
$90.25
|
| Rate for Payer: Monida First Choice Health |
$92.15
|
| Rate for Payer: Monida Montana Health Co-op |
$90.25
|
| Rate for Payer: Monida PacificSource |
$90.25
|
|
|
MAGNESIUM CITRATE BTL [10 OZ]
|
Facility
|
IP
|
$17.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
3000301
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.90 |
| Max. Negotiated Rate |
$17.00 |
| Rate for Payer: Aetna Commercial |
$16.15
|
| Rate for Payer: Aetna Medicare |
$15.30
|
| Rate for Payer: BCBS MT CHIP |
$15.30
|
| Rate for Payer: BCBS MT Closed Plan Network |
$16.15
|
| Rate for Payer: BCBS MT HealthLink |
$15.30
|
| Rate for Payer: BCBS MT Medicare |
$15.30
|
| Rate for Payer: BCBS MT POS |
$16.15
|
| Rate for Payer: BCBS MT Traditional |
$17.00
|
| Rate for Payer: Cash Price |
$15.30
|
| Rate for Payer: Cigna Commercial |
$16.15
|
| Rate for Payer: Cigna Medicare |
$15.30
|
| Rate for Payer: Medicaid All Medicaid |
$15.64
|
| Rate for Payer: Medicare All Medicare |
$11.90
|
| Rate for Payer: Monida Allegiance |
$16.15
|
| Rate for Payer: Monida First Choice Health |
$16.49
|
| Rate for Payer: Monida Montana Health Co-op |
$16.15
|
| Rate for Payer: Monida PacificSource |
$16.15
|
|
|
MAGNESIUM CITRATE BTL [10 OZ]
|
Facility
|
OP
|
$17.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
3000301
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.90 |
| Max. Negotiated Rate |
$17.00 |
| Rate for Payer: Aetna Commercial |
$16.15
|
| Rate for Payer: Aetna Medicare |
$15.30
|
| Rate for Payer: BCBS MT CHIP |
$15.30
|
| Rate for Payer: BCBS MT Closed Plan Network |
$16.15
|
| Rate for Payer: BCBS MT HealthLink |
$15.30
|
| Rate for Payer: BCBS MT Medicare |
$15.30
|
| Rate for Payer: BCBS MT POS |
$16.15
|
| Rate for Payer: BCBS MT Traditional |
$17.00
|
| Rate for Payer: Cash Price |
$15.30
|
| Rate for Payer: Cigna Commercial |
$16.15
|
| Rate for Payer: Cigna Medicare |
$15.30
|
| Rate for Payer: Medicaid All Medicaid |
$15.64
|
| Rate for Payer: Medicare All Medicare |
$11.90
|
| Rate for Payer: Monida Allegiance |
$16.15
|
| Rate for Payer: Monida First Choice Health |
$16.49
|
| Rate for Payer: Monida Montana Health Co-op |
$16.15
|
| Rate for Payer: Monida PacificSource |
$16.15
|
|
|
MAGNESIUM HYDROXIDE LIQ 1200 MG/15 ML
|
Facility
|
IP
|
$8.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
3000302
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.60 |
| Max. Negotiated Rate |
$8.00 |
| Rate for Payer: Aetna Commercial |
$7.60
|
| Rate for Payer: Aetna Medicare |
$7.20
|
| Rate for Payer: BCBS MT CHIP |
$7.20
|
| Rate for Payer: BCBS MT Closed Plan Network |
$7.60
|
| Rate for Payer: BCBS MT HealthLink |
$7.20
|
| Rate for Payer: BCBS MT Medicare |
$7.20
|
| Rate for Payer: BCBS MT POS |
$7.60
|
| Rate for Payer: BCBS MT Traditional |
$8.00
|
| Rate for Payer: Cash Price |
$7.20
|
| Rate for Payer: Cigna Commercial |
$7.60
|
| Rate for Payer: Cigna Medicare |
$7.20
|
| Rate for Payer: Medicaid All Medicaid |
$7.36
|
| Rate for Payer: Medicare All Medicare |
$5.60
|
| Rate for Payer: Monida Allegiance |
$7.60
|
| Rate for Payer: Monida First Choice Health |
$7.76
|
| Rate for Payer: Monida Montana Health Co-op |
$7.60
|
| Rate for Payer: Monida PacificSource |
$7.60
|
|
|
MAGNESIUM HYDROXIDE LIQ 1200 MG/15 ML
|
Facility
|
OP
|
$8.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
3000302
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.60 |
| Max. Negotiated Rate |
$8.00 |
| Rate for Payer: Aetna Commercial |
$7.60
|
| Rate for Payer: Aetna Medicare |
$7.20
|
| Rate for Payer: BCBS MT CHIP |
$7.20
|
| Rate for Payer: BCBS MT Closed Plan Network |
$7.60
|
| Rate for Payer: BCBS MT HealthLink |
$7.20
|
| Rate for Payer: BCBS MT Medicare |
$7.20
|
| Rate for Payer: BCBS MT POS |
$7.60
|
| Rate for Payer: BCBS MT Traditional |
$8.00
|
| Rate for Payer: Cash Price |
$7.20
|
| Rate for Payer: Cigna Commercial |
$7.60
|
| Rate for Payer: Cigna Medicare |
$7.20
|
| Rate for Payer: Medicaid All Medicaid |
$7.36
|
| Rate for Payer: Medicare All Medicare |
$5.60
|
| Rate for Payer: Monida Allegiance |
$7.60
|
| Rate for Payer: Monida First Choice Health |
$7.76
|
| Rate for Payer: Monida Montana Health Co-op |
$7.60
|
| Rate for Payer: Monida PacificSource |
$7.60
|
|
|
MAGNESIUM OXIDE TAB [400 MG]
|
Facility
|
IP
|
$8.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
3000303
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.60 |
| Max. Negotiated Rate |
$8.00 |
| Rate for Payer: Aetna Commercial |
$7.60
|
| Rate for Payer: Aetna Medicare |
$7.20
|
| Rate for Payer: BCBS MT CHIP |
$7.20
|
| Rate for Payer: BCBS MT Closed Plan Network |
$7.60
|
| Rate for Payer: BCBS MT HealthLink |
$7.20
|
| Rate for Payer: BCBS MT Medicare |
$7.20
|
| Rate for Payer: BCBS MT POS |
$7.60
|
| Rate for Payer: BCBS MT Traditional |
$8.00
|
| Rate for Payer: Cash Price |
$7.20
|
| Rate for Payer: Cigna Commercial |
$7.60
|
| Rate for Payer: Cigna Medicare |
$7.20
|
| Rate for Payer: Medicaid All Medicaid |
$7.36
|
| Rate for Payer: Medicare All Medicare |
$5.60
|
| Rate for Payer: Monida Allegiance |
$7.60
|
| Rate for Payer: Monida First Choice Health |
$7.76
|
| Rate for Payer: Monida Montana Health Co-op |
$7.60
|
| Rate for Payer: Monida PacificSource |
$7.60
|
|
|
MAGNESIUM OXIDE TAB [400 MG]
|
Facility
|
OP
|
$8.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
3000303
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.60 |
| Max. Negotiated Rate |
$8.00 |
| Rate for Payer: Aetna Commercial |
$7.60
|
| Rate for Payer: Aetna Medicare |
$7.20
|
| Rate for Payer: BCBS MT CHIP |
$7.20
|
| Rate for Payer: BCBS MT Closed Plan Network |
$7.60
|
| Rate for Payer: BCBS MT HealthLink |
$7.20
|
| Rate for Payer: BCBS MT Medicare |
$7.20
|
| Rate for Payer: BCBS MT POS |
$7.60
|
| Rate for Payer: BCBS MT Traditional |
$8.00
|
| Rate for Payer: Cash Price |
$7.20
|
| Rate for Payer: Cigna Commercial |
$7.60
|
| Rate for Payer: Cigna Medicare |
$7.20
|
| Rate for Payer: Medicaid All Medicaid |
$7.36
|
| Rate for Payer: Medicare All Medicare |
$5.60
|
| Rate for Payer: Monida Allegiance |
$7.60
|
| Rate for Payer: Monida First Choice Health |
$7.76
|
| Rate for Payer: Monida Montana Health Co-op |
$7.60
|
| Rate for Payer: Monida PacificSource |
$7.60
|
|
|
MAGNESIUM, RBC (080283)
|
Facility
|
IP
|
$118.00
|
|
|
Service Code
|
HCPCS 83735
|
| Hospital Charge Code |
4000061
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$82.60 |
| Max. Negotiated Rate |
$118.00 |
| Rate for Payer: Aetna Commercial |
$112.10
|
| Rate for Payer: Aetna Medicare |
$106.20
|
| Rate for Payer: BCBS MT CHIP |
$106.20
|
| Rate for Payer: BCBS MT Closed Plan Network |
$112.10
|
| Rate for Payer: BCBS MT HealthLink |
$106.20
|
| Rate for Payer: BCBS MT Medicare |
$106.20
|
| Rate for Payer: BCBS MT POS |
$112.10
|
| Rate for Payer: BCBS MT Traditional |
$118.00
|
| Rate for Payer: Cash Price |
$106.20
|
| Rate for Payer: Cigna Commercial |
$112.10
|
| Rate for Payer: Cigna Medicare |
$106.20
|
| Rate for Payer: Medicaid All Medicaid |
$108.56
|
| Rate for Payer: Medicare All Medicare |
$82.60
|
| Rate for Payer: Monida Allegiance |
$112.10
|
| Rate for Payer: Monida First Choice Health |
$114.46
|
| Rate for Payer: Monida Montana Health Co-op |
$112.10
|
| Rate for Payer: Monida PacificSource |
$112.10
|
|
|
MAGNESIUM, RBC (080283)
|
Facility
|
OP
|
$118.00
|
|
|
Service Code
|
HCPCS 83735
|
| Hospital Charge Code |
4000061
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$82.60 |
| Max. Negotiated Rate |
$118.00 |
| Rate for Payer: Aetna Commercial |
$112.10
|
| Rate for Payer: Aetna Medicare |
$106.20
|
| Rate for Payer: BCBS MT CHIP |
$106.20
|
| Rate for Payer: BCBS MT Closed Plan Network |
$112.10
|
| Rate for Payer: BCBS MT HealthLink |
$106.20
|
| Rate for Payer: BCBS MT Medicare |
$106.20
|
| Rate for Payer: BCBS MT POS |
$112.10
|
| Rate for Payer: BCBS MT Traditional |
$118.00
|
| Rate for Payer: Cash Price |
$106.20
|
| Rate for Payer: Cigna Commercial |
$112.10
|
| Rate for Payer: Cigna Medicare |
$106.20
|
| Rate for Payer: Medicaid All Medicaid |
$108.56
|
| Rate for Payer: Medicare All Medicare |
$82.60
|
| Rate for Payer: Monida Allegiance |
$112.10
|
| Rate for Payer: Monida First Choice Health |
$114.46
|
| Rate for Payer: Monida Montana Health Co-op |
$112.10
|
| Rate for Payer: Monida PacificSource |
$112.10
|
|
|
MAGNESIUM SUL 1G INJ [500 MG/ML] 2ML SDV
|
Facility
|
IP
|
$26.00
|
|
|
Service Code
|
HCPCS J3475
|
| Hospital Charge Code |
3000304
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$18.20 |
| Max. Negotiated Rate |
$26.00 |
| Rate for Payer: Aetna Commercial |
$24.70
|
| Rate for Payer: Aetna Medicare |
$23.40
|
| Rate for Payer: BCBS MT CHIP |
$23.40
|
| Rate for Payer: BCBS MT Closed Plan Network |
$24.70
|
| Rate for Payer: BCBS MT HealthLink |
$23.40
|
| Rate for Payer: BCBS MT Medicare |
$23.40
|
| Rate for Payer: BCBS MT POS |
$24.70
|
| Rate for Payer: BCBS MT Traditional |
$26.00
|
| Rate for Payer: Cash Price |
$23.40
|
| Rate for Payer: Cigna Commercial |
$24.70
|
| Rate for Payer: Cigna Medicare |
$23.40
|
| Rate for Payer: Medicaid All Medicaid |
$23.92
|
| Rate for Payer: Medicare All Medicare |
$18.20
|
| Rate for Payer: Monida Allegiance |
$24.70
|
| Rate for Payer: Monida First Choice Health |
$25.22
|
| Rate for Payer: Monida Montana Health Co-op |
$24.70
|
| Rate for Payer: Monida PacificSource |
$24.70
|
|
|
MAGNESIUM SUL 1G INJ [500 MG/ML] 2ML SDV
|
Facility
|
OP
|
$26.00
|
|
|
Service Code
|
HCPCS J3475
|
| Hospital Charge Code |
3000304
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$18.20 |
| Max. Negotiated Rate |
$26.00 |
| Rate for Payer: Aetna Commercial |
$24.70
|
| Rate for Payer: Aetna Medicare |
$23.40
|
| Rate for Payer: BCBS MT CHIP |
$23.40
|
| Rate for Payer: BCBS MT Closed Plan Network |
$24.70
|
| Rate for Payer: BCBS MT HealthLink |
$23.40
|
| Rate for Payer: BCBS MT Medicare |
$23.40
|
| Rate for Payer: BCBS MT POS |
$24.70
|
| Rate for Payer: BCBS MT Traditional |
$26.00
|
| Rate for Payer: Cash Price |
$23.40
|
| Rate for Payer: Cigna Commercial |
$24.70
|
| Rate for Payer: Cigna Medicare |
$23.40
|
| Rate for Payer: Medicaid All Medicaid |
$23.92
|
| Rate for Payer: Medicare All Medicare |
$18.20
|
| Rate for Payer: Monida Allegiance |
$24.70
|
| Rate for Payer: Monida First Choice Health |
$25.22
|
| Rate for Payer: Monida Montana Health Co-op |
$24.70
|
| Rate for Payer: Monida PacificSource |
$24.70
|
|
|
MAGNESIUM SULFATE/D5W 1GM/100ML PREMIX
|
Facility
|
OP
|
$33.00
|
|
|
Service Code
|
HCPCS J3475
|
| Hospital Charge Code |
3007070
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$23.10 |
| Max. Negotiated Rate |
$33.00 |
| Rate for Payer: Aetna Commercial |
$31.35
|
| Rate for Payer: Aetna Medicare |
$29.70
|
| Rate for Payer: BCBS MT CHIP |
$29.70
|
| Rate for Payer: BCBS MT Closed Plan Network |
$31.35
|
| Rate for Payer: BCBS MT HealthLink |
$29.70
|
| Rate for Payer: BCBS MT Medicare |
$29.70
|
| Rate for Payer: BCBS MT POS |
$31.35
|
| Rate for Payer: BCBS MT Traditional |
$33.00
|
| Rate for Payer: Cash Price |
$29.70
|
| Rate for Payer: Cigna Commercial |
$31.35
|
| Rate for Payer: Cigna Medicare |
$29.70
|
| Rate for Payer: Medicaid All Medicaid |
$30.36
|
| Rate for Payer: Medicare All Medicare |
$23.10
|
| Rate for Payer: Monida Allegiance |
$31.35
|
| Rate for Payer: Monida First Choice Health |
$32.01
|
| Rate for Payer: Monida Montana Health Co-op |
$31.35
|
| Rate for Payer: Monida PacificSource |
$31.35
|
|
|
MAGNESIUM SULFATE/D5W 1GM/100ML PREMIX
|
Facility
|
IP
|
$33.00
|
|
|
Service Code
|
HCPCS J3475
|
| Hospital Charge Code |
3007070
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$23.10 |
| Max. Negotiated Rate |
$33.00 |
| Rate for Payer: Aetna Commercial |
$31.35
|
| Rate for Payer: Aetna Medicare |
$29.70
|
| Rate for Payer: BCBS MT CHIP |
$29.70
|
| Rate for Payer: BCBS MT Closed Plan Network |
$31.35
|
| Rate for Payer: BCBS MT HealthLink |
$29.70
|
| Rate for Payer: BCBS MT Medicare |
$29.70
|
| Rate for Payer: BCBS MT POS |
$31.35
|
| Rate for Payer: BCBS MT Traditional |
$33.00
|
| Rate for Payer: Cash Price |
$29.70
|
| Rate for Payer: Cigna Commercial |
$31.35
|
| Rate for Payer: Cigna Medicare |
$29.70
|
| Rate for Payer: Medicaid All Medicaid |
$30.36
|
| Rate for Payer: Medicare All Medicare |
$23.10
|
| Rate for Payer: Monida Allegiance |
$31.35
|
| Rate for Payer: Monida First Choice Health |
$32.01
|
| Rate for Payer: Monida Montana Health Co-op |
$31.35
|
| Rate for Payer: Monida PacificSource |
$31.35
|
|
|
MAGNESIUM SULF/WATER [2GM/50ML] PREMIX
|
Facility
|
OP
|
$17.00
|
|
|
Service Code
|
NDC 00264420452
|
| Hospital Charge Code |
3000535
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$11.90 |
| Max. Negotiated Rate |
$17.00 |
| Rate for Payer: Aetna Commercial |
$16.15
|
| Rate for Payer: Aetna Medicare |
$15.30
|
| Rate for Payer: BCBS MT CHIP |
$15.30
|
| Rate for Payer: BCBS MT Closed Plan Network |
$16.15
|
| Rate for Payer: BCBS MT HealthLink |
$15.30
|
| Rate for Payer: BCBS MT Medicare |
$15.30
|
| Rate for Payer: BCBS MT POS |
$16.15
|
| Rate for Payer: BCBS MT Traditional |
$17.00
|
| Rate for Payer: Cash Price |
$15.30
|
| Rate for Payer: Cigna Commercial |
$16.15
|
| Rate for Payer: Cigna Medicare |
$15.30
|
| Rate for Payer: Medicaid All Medicaid |
$15.64
|
| Rate for Payer: Medicare All Medicare |
$11.90
|
| Rate for Payer: Monida Allegiance |
$16.15
|
| Rate for Payer: Monida First Choice Health |
$16.49
|
| Rate for Payer: Monida Montana Health Co-op |
$16.15
|
| Rate for Payer: Monida PacificSource |
$16.15
|
|
|
MAGNESIUM SULF/WATER [2GM/50ML] PREMIX
|
Facility
|
IP
|
$17.00
|
|
|
Service Code
|
NDC 00264420452
|
| Hospital Charge Code |
3000535
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$11.90 |
| Max. Negotiated Rate |
$17.00 |
| Rate for Payer: Aetna Commercial |
$16.15
|
| Rate for Payer: Aetna Medicare |
$15.30
|
| Rate for Payer: BCBS MT CHIP |
$15.30
|
| Rate for Payer: BCBS MT Closed Plan Network |
$16.15
|
| Rate for Payer: BCBS MT HealthLink |
$15.30
|
| Rate for Payer: BCBS MT Medicare |
$15.30
|
| Rate for Payer: BCBS MT POS |
$16.15
|
| Rate for Payer: BCBS MT Traditional |
$17.00
|
| Rate for Payer: Cash Price |
$15.30
|
| Rate for Payer: Cigna Commercial |
$16.15
|
| Rate for Payer: Cigna Medicare |
$15.30
|
| Rate for Payer: Medicaid All Medicaid |
$15.64
|
| Rate for Payer: Medicare All Medicare |
$11.90
|
| Rate for Payer: Monida Allegiance |
$16.15
|
| Rate for Payer: Monida First Choice Health |
$16.49
|
| Rate for Payer: Monida Montana Health Co-op |
$16.15
|
| Rate for Payer: Monida PacificSource |
$16.15
|
|
|
.MANUAL DIFFERENTIAL, BLOOD
|
Facility
|
OP
|
$50.00
|
|
|
Service Code
|
HCPCS 85007
|
| Hospital Charge Code |
4085007
|
|
Hospital Revenue Code
|
305
|
| Min. Negotiated Rate |
$35.00 |
| Max. Negotiated Rate |
$50.00 |
| Rate for Payer: Aetna Commercial |
$47.50
|
| Rate for Payer: Aetna Medicare |
$45.00
|
| Rate for Payer: BCBS MT CHIP |
$45.00
|
| Rate for Payer: BCBS MT Closed Plan Network |
$47.50
|
| Rate for Payer: BCBS MT HealthLink |
$45.00
|
| Rate for Payer: BCBS MT Medicare |
$45.00
|
| Rate for Payer: BCBS MT POS |
$47.50
|
| Rate for Payer: BCBS MT Traditional |
$50.00
|
| Rate for Payer: Cash Price |
$45.00
|
| Rate for Payer: Cigna Commercial |
$47.50
|
| Rate for Payer: Cigna Medicare |
$45.00
|
| Rate for Payer: Medicaid All Medicaid |
$46.00
|
| Rate for Payer: Medicare All Medicare |
$35.00
|
| Rate for Payer: Monida Allegiance |
$47.50
|
| Rate for Payer: Monida First Choice Health |
$48.50
|
| Rate for Payer: Monida Montana Health Co-op |
$47.50
|
| Rate for Payer: Monida PacificSource |
$47.50
|
|
|
.MANUAL DIFFERENTIAL, BLOOD
|
Facility
|
IP
|
$50.00
|
|
|
Service Code
|
HCPCS 85007
|
| Hospital Charge Code |
4085007
|
|
Hospital Revenue Code
|
305
|
| Min. Negotiated Rate |
$35.00 |
| Max. Negotiated Rate |
$50.00 |
| Rate for Payer: Aetna Commercial |
$47.50
|
| Rate for Payer: Aetna Medicare |
$45.00
|
| Rate for Payer: BCBS MT CHIP |
$45.00
|
| Rate for Payer: BCBS MT Closed Plan Network |
$47.50
|
| Rate for Payer: BCBS MT HealthLink |
$45.00
|
| Rate for Payer: BCBS MT Medicare |
$45.00
|
| Rate for Payer: BCBS MT POS |
$47.50
|
| Rate for Payer: BCBS MT Traditional |
$50.00
|
| Rate for Payer: Cash Price |
$45.00
|
| Rate for Payer: Cigna Commercial |
$47.50
|
| Rate for Payer: Cigna Medicare |
$45.00
|
| Rate for Payer: Medicaid All Medicaid |
$46.00
|
| Rate for Payer: Medicare All Medicare |
$35.00
|
| Rate for Payer: Monida Allegiance |
$47.50
|
| Rate for Payer: Monida First Choice Health |
$48.50
|
| Rate for Payer: Monida Montana Health Co-op |
$47.50
|
| Rate for Payer: Monida PacificSource |
$47.50
|
|
|
MASK #1 PROCEDURE (BLUE)
|
Facility
|
IP
|
$4.00
|
|
| Hospital Charge Code |
80093167
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$2.80 |
| Max. Negotiated Rate |
$4.00 |
| Rate for Payer: Aetna Commercial |
$3.80
|
| Rate for Payer: Aetna Medicare |
$3.60
|
| Rate for Payer: BCBS MT CHIP |
$3.60
|
| Rate for Payer: BCBS MT Closed Plan Network |
$3.80
|
| Rate for Payer: BCBS MT HealthLink |
$3.60
|
| Rate for Payer: BCBS MT Medicare |
$3.60
|
| Rate for Payer: BCBS MT POS |
$3.80
|
| Rate for Payer: BCBS MT Traditional |
$4.00
|
| Rate for Payer: Cash Price |
$3.60
|
| Rate for Payer: Cigna Commercial |
$3.80
|
| Rate for Payer: Cigna Medicare |
$3.60
|
| Rate for Payer: Medicaid All Medicaid |
$3.68
|
| Rate for Payer: Medicare All Medicare |
$2.80
|
| Rate for Payer: Monida Allegiance |
$3.80
|
| Rate for Payer: Monida First Choice Health |
$3.88
|
| Rate for Payer: Monida Montana Health Co-op |
$3.80
|
| Rate for Payer: Monida PacificSource |
$3.80
|
|
|
MASK #1 PROCEDURE (BLUE)
|
Facility
|
OP
|
$4.00
|
|
| Hospital Charge Code |
80093167
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$2.80 |
| Max. Negotiated Rate |
$4.00 |
| Rate for Payer: Aetna Commercial |
$3.80
|
| Rate for Payer: Aetna Medicare |
$3.60
|
| Rate for Payer: BCBS MT CHIP |
$3.60
|
| Rate for Payer: BCBS MT Closed Plan Network |
$3.80
|
| Rate for Payer: BCBS MT HealthLink |
$3.60
|
| Rate for Payer: BCBS MT Medicare |
$3.60
|
| Rate for Payer: BCBS MT POS |
$3.80
|
| Rate for Payer: BCBS MT Traditional |
$4.00
|
| Rate for Payer: Cash Price |
$3.60
|
| Rate for Payer: Cigna Commercial |
$3.80
|
| Rate for Payer: Cigna Medicare |
$3.60
|
| Rate for Payer: Medicaid All Medicaid |
$3.68
|
| Rate for Payer: Medicare All Medicare |
$2.80
|
| Rate for Payer: Monida Allegiance |
$3.80
|
| Rate for Payer: Monida First Choice Health |
$3.88
|
| Rate for Payer: Monida Montana Health Co-op |
$3.80
|
| Rate for Payer: Monida PacificSource |
$3.80
|
|
|
MASK CHILD PROCEDURE MASK
|
Facility
|
IP
|
$20.00
|
|
| Hospital Charge Code |
80030244
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$14.00 |
| Max. Negotiated Rate |
$20.00 |
| Rate for Payer: Aetna Commercial |
$19.00
|
| Rate for Payer: Aetna Medicare |
$18.00
|
| Rate for Payer: BCBS MT CHIP |
$18.00
|
| Rate for Payer: BCBS MT Closed Plan Network |
$19.00
|
| Rate for Payer: BCBS MT HealthLink |
$18.00
|
| Rate for Payer: BCBS MT Medicare |
$18.00
|
| Rate for Payer: BCBS MT POS |
$19.00
|
| Rate for Payer: BCBS MT Traditional |
$20.00
|
| Rate for Payer: Cash Price |
$18.00
|
| Rate for Payer: Cigna Commercial |
$19.00
|
| Rate for Payer: Cigna Medicare |
$18.00
|
| Rate for Payer: Medicaid All Medicaid |
$18.40
|
| Rate for Payer: Medicare All Medicare |
$14.00
|
| Rate for Payer: Monida Allegiance |
$19.00
|
| Rate for Payer: Monida First Choice Health |
$19.40
|
| Rate for Payer: Monida Montana Health Co-op |
$19.00
|
| Rate for Payer: Monida PacificSource |
$19.00
|
|
|
MASK CHILD PROCEDURE MASK
|
Facility
|
OP
|
$20.00
|
|
| Hospital Charge Code |
80030244
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$14.00 |
| Max. Negotiated Rate |
$20.00 |
| Rate for Payer: Aetna Commercial |
$19.00
|
| Rate for Payer: Aetna Medicare |
$18.00
|
| Rate for Payer: BCBS MT CHIP |
$18.00
|
| Rate for Payer: BCBS MT Closed Plan Network |
$19.00
|
| Rate for Payer: BCBS MT HealthLink |
$18.00
|
| Rate for Payer: BCBS MT Medicare |
$18.00
|
| Rate for Payer: BCBS MT POS |
$19.00
|
| Rate for Payer: BCBS MT Traditional |
$20.00
|
| Rate for Payer: Cash Price |
$18.00
|
| Rate for Payer: Cigna Commercial |
$19.00
|
| Rate for Payer: Cigna Medicare |
$18.00
|
| Rate for Payer: Medicaid All Medicaid |
$18.40
|
| Rate for Payer: Medicare All Medicare |
$14.00
|
| Rate for Payer: Monida Allegiance |
$19.00
|
| Rate for Payer: Monida First Choice Health |
$19.40
|
| Rate for Payer: Monida Montana Health Co-op |
$19.00
|
| Rate for Payer: Monida PacificSource |
$19.00
|
|
|
MATERNITY PAD
|
Facility
|
OP
|
$5.00
|
|
| Hospital Charge Code |
80030459
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$3.50 |
| Max. Negotiated Rate |
$5.00 |
| Rate for Payer: Aetna Commercial |
$4.75
|
| Rate for Payer: Aetna Medicare |
$4.50
|
| Rate for Payer: BCBS MT CHIP |
$4.50
|
| Rate for Payer: BCBS MT Closed Plan Network |
$4.75
|
| Rate for Payer: BCBS MT HealthLink |
$4.50
|
| Rate for Payer: BCBS MT Medicare |
$4.50
|
| Rate for Payer: BCBS MT POS |
$4.75
|
| Rate for Payer: BCBS MT Traditional |
$5.00
|
| Rate for Payer: Cash Price |
$4.50
|
| Rate for Payer: Cigna Commercial |
$4.75
|
| Rate for Payer: Cigna Medicare |
$4.50
|
| Rate for Payer: Medicaid All Medicaid |
$4.60
|
| Rate for Payer: Medicare All Medicare |
$3.50
|
| Rate for Payer: Monida Allegiance |
$4.75
|
| Rate for Payer: Monida First Choice Health |
$4.85
|
| Rate for Payer: Monida Montana Health Co-op |
$4.75
|
| Rate for Payer: Monida PacificSource |
$4.75
|
|
|
MATERNITY PAD
|
Facility
|
IP
|
$5.00
|
|
| Hospital Charge Code |
80030459
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$3.50 |
| Max. Negotiated Rate |
$5.00 |
| Rate for Payer: Aetna Commercial |
$4.75
|
| Rate for Payer: Aetna Medicare |
$4.50
|
| Rate for Payer: BCBS MT CHIP |
$4.50
|
| Rate for Payer: BCBS MT Closed Plan Network |
$4.75
|
| Rate for Payer: BCBS MT HealthLink |
$4.50
|
| Rate for Payer: BCBS MT Medicare |
$4.50
|
| Rate for Payer: BCBS MT POS |
$4.75
|
| Rate for Payer: BCBS MT Traditional |
$5.00
|
| Rate for Payer: Cash Price |
$4.50
|
| Rate for Payer: Cigna Commercial |
$4.75
|
| Rate for Payer: Cigna Medicare |
$4.50
|
| Rate for Payer: Medicaid All Medicaid |
$4.60
|
| Rate for Payer: Medicare All Medicare |
$3.50
|
| Rate for Payer: Monida Allegiance |
$4.75
|
| Rate for Payer: Monida First Choice Health |
$4.85
|
| Rate for Payer: Monida Montana Health Co-op |
$4.75
|
| Rate for Payer: Monida PacificSource |
$4.75
|
|
|
MAXORB ALGINATE DRESSING MSC94
|
Facility
|
IP
|
$21.00
|
|
| Hospital Charge Code |
80040067
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$14.70 |
| Max. Negotiated Rate |
$21.00 |
| Rate for Payer: Aetna Commercial |
$19.95
|
| Rate for Payer: Aetna Medicare |
$18.90
|
| Rate for Payer: BCBS MT CHIP |
$18.90
|
| Rate for Payer: BCBS MT Closed Plan Network |
$19.95
|
| Rate for Payer: BCBS MT HealthLink |
$18.90
|
| Rate for Payer: BCBS MT Medicare |
$18.90
|
| Rate for Payer: BCBS MT POS |
$19.95
|
| Rate for Payer: BCBS MT Traditional |
$21.00
|
| Rate for Payer: Cash Price |
$18.90
|
| Rate for Payer: Cigna Commercial |
$19.95
|
| Rate for Payer: Cigna Medicare |
$18.90
|
| Rate for Payer: Medicaid All Medicaid |
$19.32
|
| Rate for Payer: Medicare All Medicare |
$14.70
|
| Rate for Payer: Monida Allegiance |
$19.95
|
| Rate for Payer: Monida First Choice Health |
$20.37
|
| Rate for Payer: Monida Montana Health Co-op |
$19.95
|
| Rate for Payer: Monida PacificSource |
$19.95
|
|
