|
IPRATROP/ALBUTEROL MDI [20/100MCG] NF
|
Facility
|
OP
|
$999.00
|
|
|
Service Code
|
HCPCS J7620
|
| Hospital Charge Code |
3000237
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$699.30 |
| Max. Negotiated Rate |
$999.00 |
| Rate for Payer: Aetna Commercial |
$949.05
|
| Rate for Payer: Aetna Medicare |
$899.10
|
| Rate for Payer: BCBS MT CHIP |
$899.10
|
| Rate for Payer: BCBS MT Closed Plan Network |
$949.05
|
| Rate for Payer: BCBS MT HealthLink |
$899.10
|
| Rate for Payer: BCBS MT Medicare |
$899.10
|
| Rate for Payer: BCBS MT POS |
$949.05
|
| Rate for Payer: BCBS MT Traditional |
$999.00
|
| Rate for Payer: Cash Price |
$899.10
|
| Rate for Payer: Cigna Commercial |
$949.05
|
| Rate for Payer: Cigna Medicare |
$899.10
|
| Rate for Payer: Medicaid All Medicaid |
$919.08
|
| Rate for Payer: Medicare All Medicare |
$699.30
|
| Rate for Payer: Monida Allegiance |
$949.05
|
| Rate for Payer: Monida First Choice Health |
$969.03
|
| Rate for Payer: Monida Montana Health Co-op |
$949.05
|
| Rate for Payer: Monida PacificSource |
$949.05
|
|
|
IPRATROPIUM HFA INH (17 MCG) NF
|
Facility
|
OP
|
$700.00
|
|
| Hospital Charge Code |
3007298
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$490.00 |
| Max. Negotiated Rate |
$700.00 |
| Rate for Payer: Aetna Commercial |
$665.00
|
| Rate for Payer: Aetna Medicare |
$630.00
|
| Rate for Payer: BCBS MT CHIP |
$630.00
|
| Rate for Payer: BCBS MT Closed Plan Network |
$665.00
|
| Rate for Payer: BCBS MT HealthLink |
$630.00
|
| Rate for Payer: BCBS MT Medicare |
$630.00
|
| Rate for Payer: BCBS MT POS |
$665.00
|
| Rate for Payer: BCBS MT Traditional |
$700.00
|
| Rate for Payer: Cash Price |
$630.00
|
| Rate for Payer: Cigna Commercial |
$665.00
|
| Rate for Payer: Cigna Medicare |
$630.00
|
| Rate for Payer: Medicaid All Medicaid |
$644.00
|
| Rate for Payer: Medicare All Medicare |
$490.00
|
| Rate for Payer: Monida Allegiance |
$665.00
|
| Rate for Payer: Monida First Choice Health |
$679.00
|
| Rate for Payer: Monida Montana Health Co-op |
$665.00
|
| Rate for Payer: Monida PacificSource |
$665.00
|
|
|
IPRATROPIUM HFA INH (17 MCG) NF
|
Facility
|
IP
|
$700.00
|
|
| Hospital Charge Code |
3007298
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$490.00 |
| Max. Negotiated Rate |
$700.00 |
| Rate for Payer: Aetna Commercial |
$665.00
|
| Rate for Payer: Aetna Medicare |
$630.00
|
| Rate for Payer: BCBS MT CHIP |
$630.00
|
| Rate for Payer: BCBS MT Closed Plan Network |
$665.00
|
| Rate for Payer: BCBS MT HealthLink |
$630.00
|
| Rate for Payer: BCBS MT Medicare |
$630.00
|
| Rate for Payer: BCBS MT POS |
$665.00
|
| Rate for Payer: BCBS MT Traditional |
$700.00
|
| Rate for Payer: Cash Price |
$630.00
|
| Rate for Payer: Cigna Commercial |
$665.00
|
| Rate for Payer: Cigna Medicare |
$630.00
|
| Rate for Payer: Medicaid All Medicaid |
$644.00
|
| Rate for Payer: Medicare All Medicare |
$490.00
|
| Rate for Payer: Monida Allegiance |
$665.00
|
| Rate for Payer: Monida First Choice Health |
$679.00
|
| Rate for Payer: Monida Montana Health Co-op |
$665.00
|
| Rate for Payer: Monida PacificSource |
$665.00
|
|
|
IPRATROPIUM NEB [0.02 %] SLN
|
Facility
|
OP
|
$8.00
|
|
|
Service Code
|
HCPCS J7644
|
| Hospital Charge Code |
3000238
|
|
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
|
|
|
IPRATROPIUM NEB [0.02 %] SLN
|
Facility
|
IP
|
$8.00
|
|
|
Service Code
|
HCPCS J7644
|
| Hospital Charge Code |
3000238
|
|
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
|
|
|
IRBESARTAN [75MG] NF
|
Facility
|
IP
|
$8.00
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
3000503
|
|
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
|
|
|
IRBESARTAN [75MG] NF
|
Facility
|
OP
|
$8.00
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
3000503
|
|
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
|
|
|
IRON ASSAY
|
Facility
|
OP
|
$90.00
|
|
| Hospital Charge Code |
90197101
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$63.00 |
| Max. Negotiated Rate |
$90.00 |
| Rate for Payer: Aetna Commercial |
$85.50
|
| Rate for Payer: Aetna Medicare |
$81.00
|
| Rate for Payer: BCBS MT CHIP |
$81.00
|
| Rate for Payer: BCBS MT Closed Plan Network |
$85.50
|
| Rate for Payer: BCBS MT HealthLink |
$81.00
|
| Rate for Payer: BCBS MT Medicare |
$81.00
|
| Rate for Payer: BCBS MT POS |
$85.50
|
| Rate for Payer: BCBS MT Traditional |
$90.00
|
| Rate for Payer: Cash Price |
$81.00
|
| Rate for Payer: Cigna Commercial |
$85.50
|
| Rate for Payer: Cigna Medicare |
$81.00
|
| Rate for Payer: Medicaid All Medicaid |
$82.80
|
| Rate for Payer: Medicare All Medicare |
$63.00
|
| Rate for Payer: Monida Allegiance |
$85.50
|
| Rate for Payer: Monida First Choice Health |
$87.30
|
| Rate for Payer: Monida Montana Health Co-op |
$85.50
|
| Rate for Payer: Monida PacificSource |
$85.50
|
|
|
IRON ASSAY
|
Facility
|
IP
|
$90.00
|
|
| Hospital Charge Code |
90197101
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$63.00 |
| Max. Negotiated Rate |
$90.00 |
| Rate for Payer: Aetna Commercial |
$85.50
|
| Rate for Payer: Aetna Medicare |
$81.00
|
| Rate for Payer: BCBS MT CHIP |
$81.00
|
| Rate for Payer: BCBS MT Closed Plan Network |
$85.50
|
| Rate for Payer: BCBS MT HealthLink |
$81.00
|
| Rate for Payer: BCBS MT Medicare |
$81.00
|
| Rate for Payer: BCBS MT POS |
$85.50
|
| Rate for Payer: BCBS MT Traditional |
$90.00
|
| Rate for Payer: Cash Price |
$81.00
|
| Rate for Payer: Cigna Commercial |
$85.50
|
| Rate for Payer: Cigna Medicare |
$81.00
|
| Rate for Payer: Medicaid All Medicaid |
$82.80
|
| Rate for Payer: Medicare All Medicare |
$63.00
|
| Rate for Payer: Monida Allegiance |
$85.50
|
| Rate for Payer: Monida First Choice Health |
$87.30
|
| Rate for Payer: Monida Montana Health Co-op |
$85.50
|
| Rate for Payer: Monida PacificSource |
$85.50
|
|
|
IRON DEXTRAN INJ [100 MG/2 ML]
|
Facility
|
OP
|
$144.00
|
|
|
Service Code
|
HCPCS J1750
|
| Hospital Charge Code |
3000587
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$100.80 |
| Max. Negotiated Rate |
$144.00 |
| Rate for Payer: Aetna Commercial |
$136.80
|
| Rate for Payer: Aetna Medicare |
$129.60
|
| Rate for Payer: BCBS MT CHIP |
$129.60
|
| Rate for Payer: BCBS MT Closed Plan Network |
$136.80
|
| Rate for Payer: BCBS MT HealthLink |
$129.60
|
| Rate for Payer: BCBS MT Medicare |
$129.60
|
| Rate for Payer: BCBS MT POS |
$136.80
|
| Rate for Payer: BCBS MT Traditional |
$144.00
|
| Rate for Payer: Cash Price |
$129.60
|
| Rate for Payer: Cigna Commercial |
$136.80
|
| Rate for Payer: Cigna Medicare |
$129.60
|
| Rate for Payer: Medicaid All Medicaid |
$132.48
|
| Rate for Payer: Medicare All Medicare |
$100.80
|
| Rate for Payer: Monida Allegiance |
$136.80
|
| Rate for Payer: Monida First Choice Health |
$139.68
|
| Rate for Payer: Monida Montana Health Co-op |
$136.80
|
| Rate for Payer: Monida PacificSource |
$136.80
|
|
|
IRON DEXTRAN INJ [100 MG/2 ML]
|
Facility
|
IP
|
$144.00
|
|
|
Service Code
|
HCPCS J1750
|
| Hospital Charge Code |
3000587
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$100.80 |
| Max. Negotiated Rate |
$144.00 |
| Rate for Payer: Aetna Commercial |
$136.80
|
| Rate for Payer: Aetna Medicare |
$129.60
|
| Rate for Payer: BCBS MT CHIP |
$129.60
|
| Rate for Payer: BCBS MT Closed Plan Network |
$136.80
|
| Rate for Payer: BCBS MT HealthLink |
$129.60
|
| Rate for Payer: BCBS MT Medicare |
$129.60
|
| Rate for Payer: BCBS MT POS |
$136.80
|
| Rate for Payer: BCBS MT Traditional |
$144.00
|
| Rate for Payer: Cash Price |
$129.60
|
| Rate for Payer: Cigna Commercial |
$136.80
|
| Rate for Payer: Cigna Medicare |
$129.60
|
| Rate for Payer: Medicaid All Medicaid |
$132.48
|
| Rate for Payer: Medicare All Medicare |
$100.80
|
| Rate for Payer: Monida Allegiance |
$136.80
|
| Rate for Payer: Monida First Choice Health |
$139.68
|
| Rate for Payer: Monida Montana Health Co-op |
$136.80
|
| Rate for Payer: Monida PacificSource |
$136.80
|
|
|
IRON SUCROSE INJ 20MG/ML (10ML VIAL)
|
Facility
|
OP
|
$443.60
|
|
|
Service Code
|
HCPCS J1756
|
| Hospital Charge Code |
3007258
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$310.52 |
| Max. Negotiated Rate |
$443.60 |
| Rate for Payer: Aetna Commercial |
$421.42
|
| Rate for Payer: Aetna Medicare |
$399.24
|
| Rate for Payer: BCBS MT CHIP |
$399.24
|
| Rate for Payer: BCBS MT Closed Plan Network |
$421.42
|
| Rate for Payer: BCBS MT HealthLink |
$399.24
|
| Rate for Payer: BCBS MT Medicare |
$399.24
|
| Rate for Payer: BCBS MT POS |
$421.42
|
| Rate for Payer: BCBS MT Traditional |
$443.60
|
| Rate for Payer: Cash Price |
$399.24
|
| Rate for Payer: Cigna Commercial |
$421.42
|
| Rate for Payer: Cigna Medicare |
$399.24
|
| Rate for Payer: Medicaid All Medicaid |
$408.11
|
| Rate for Payer: Medicare All Medicare |
$310.52
|
| Rate for Payer: Monida Allegiance |
$421.42
|
| Rate for Payer: Monida First Choice Health |
$430.29
|
| Rate for Payer: Monida Montana Health Co-op |
$421.42
|
| Rate for Payer: Monida PacificSource |
$421.42
|
|
|
IRON SUCROSE INJ 20MG/ML (10ML VIAL)
|
Facility
|
IP
|
$443.60
|
|
|
Service Code
|
HCPCS J1756
|
| Hospital Charge Code |
3007258
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$310.52 |
| Max. Negotiated Rate |
$443.60 |
| Rate for Payer: Aetna Commercial |
$421.42
|
| Rate for Payer: Aetna Medicare |
$399.24
|
| Rate for Payer: BCBS MT CHIP |
$399.24
|
| Rate for Payer: BCBS MT Closed Plan Network |
$421.42
|
| Rate for Payer: BCBS MT HealthLink |
$399.24
|
| Rate for Payer: BCBS MT Medicare |
$399.24
|
| Rate for Payer: BCBS MT POS |
$421.42
|
| Rate for Payer: BCBS MT Traditional |
$443.60
|
| Rate for Payer: Cash Price |
$399.24
|
| Rate for Payer: Cigna Commercial |
$421.42
|
| Rate for Payer: Cigna Medicare |
$399.24
|
| Rate for Payer: Medicaid All Medicaid |
$408.11
|
| Rate for Payer: Medicare All Medicare |
$310.52
|
| Rate for Payer: Monida Allegiance |
$421.42
|
| Rate for Payer: Monida First Choice Health |
$430.29
|
| Rate for Payer: Monida Montana Health Co-op |
$421.42
|
| Rate for Payer: Monida PacificSource |
$421.42
|
|
|
.IRON, TOTAL
|
Facility
|
IP
|
$56.00
|
|
|
Service Code
|
CPT 83540
|
| Hospital Charge Code |
4035401
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$39.20 |
| Max. Negotiated Rate |
$56.00 |
| Rate for Payer: Aetna Commercial |
$53.20
|
| Rate for Payer: Aetna Medicare |
$50.40
|
| Rate for Payer: BCBS MT CHIP |
$50.40
|
| Rate for Payer: BCBS MT Closed Plan Network |
$53.20
|
| Rate for Payer: BCBS MT HealthLink |
$50.40
|
| Rate for Payer: BCBS MT Medicare |
$50.40
|
| Rate for Payer: BCBS MT POS |
$53.20
|
| Rate for Payer: BCBS MT Traditional |
$56.00
|
| Rate for Payer: Cash Price |
$50.40
|
| Rate for Payer: Cigna Commercial |
$53.20
|
| Rate for Payer: Cigna Medicare |
$50.40
|
| Rate for Payer: Medicaid All Medicaid |
$51.52
|
| Rate for Payer: Medicare All Medicare |
$39.20
|
| Rate for Payer: Monida Allegiance |
$53.20
|
| Rate for Payer: Monida First Choice Health |
$54.32
|
| Rate for Payer: Monida Montana Health Co-op |
$53.20
|
| Rate for Payer: Monida PacificSource |
$53.20
|
|
|
.IRON, TOTAL
|
Facility
|
OP
|
$56.00
|
|
|
Service Code
|
CPT 83540
|
| Hospital Charge Code |
4035401
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$39.20 |
| Max. Negotiated Rate |
$56.00 |
| Rate for Payer: Aetna Commercial |
$53.20
|
| Rate for Payer: Aetna Medicare |
$50.40
|
| Rate for Payer: BCBS MT CHIP |
$50.40
|
| Rate for Payer: BCBS MT Closed Plan Network |
$53.20
|
| Rate for Payer: BCBS MT HealthLink |
$50.40
|
| Rate for Payer: BCBS MT Medicare |
$50.40
|
| Rate for Payer: BCBS MT POS |
$53.20
|
| Rate for Payer: BCBS MT Traditional |
$56.00
|
| Rate for Payer: Cash Price |
$50.40
|
| Rate for Payer: Cigna Commercial |
$53.20
|
| Rate for Payer: Cigna Medicare |
$50.40
|
| Rate for Payer: Medicaid All Medicaid |
$51.52
|
| Rate for Payer: Medicare All Medicare |
$39.20
|
| Rate for Payer: Monida Allegiance |
$53.20
|
| Rate for Payer: Monida First Choice Health |
$54.32
|
| Rate for Payer: Monida Montana Health Co-op |
$53.20
|
| Rate for Payer: Monida PacificSource |
$53.20
|
|
|
IRON, TOTAL (001339)
|
Facility
|
IP
|
$56.00
|
|
|
Service Code
|
CPT 83540
|
| Hospital Charge Code |
4083540
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$39.20 |
| Max. Negotiated Rate |
$56.00 |
| Rate for Payer: Aetna Commercial |
$53.20
|
| Rate for Payer: Aetna Medicare |
$50.40
|
| Rate for Payer: BCBS MT CHIP |
$50.40
|
| Rate for Payer: BCBS MT Closed Plan Network |
$53.20
|
| Rate for Payer: BCBS MT HealthLink |
$50.40
|
| Rate for Payer: BCBS MT Medicare |
$50.40
|
| Rate for Payer: BCBS MT POS |
$53.20
|
| Rate for Payer: BCBS MT Traditional |
$56.00
|
| Rate for Payer: Cash Price |
$50.40
|
| Rate for Payer: Cigna Commercial |
$53.20
|
| Rate for Payer: Cigna Medicare |
$50.40
|
| Rate for Payer: Medicaid All Medicaid |
$51.52
|
| Rate for Payer: Medicare All Medicare |
$39.20
|
| Rate for Payer: Monida Allegiance |
$53.20
|
| Rate for Payer: Monida First Choice Health |
$54.32
|
| Rate for Payer: Monida Montana Health Co-op |
$53.20
|
| Rate for Payer: Monida PacificSource |
$53.20
|
|
|
IRON, TOTAL (001339)
|
Facility
|
OP
|
$56.00
|
|
|
Service Code
|
CPT 83540
|
| Hospital Charge Code |
4083540
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$39.20 |
| Max. Negotiated Rate |
$56.00 |
| Rate for Payer: Aetna Commercial |
$53.20
|
| Rate for Payer: Aetna Medicare |
$50.40
|
| Rate for Payer: BCBS MT CHIP |
$50.40
|
| Rate for Payer: BCBS MT Closed Plan Network |
$53.20
|
| Rate for Payer: BCBS MT HealthLink |
$50.40
|
| Rate for Payer: BCBS MT Medicare |
$50.40
|
| Rate for Payer: BCBS MT POS |
$53.20
|
| Rate for Payer: BCBS MT Traditional |
$56.00
|
| Rate for Payer: Cash Price |
$50.40
|
| Rate for Payer: Cigna Commercial |
$53.20
|
| Rate for Payer: Cigna Medicare |
$50.40
|
| Rate for Payer: Medicaid All Medicaid |
$51.52
|
| Rate for Payer: Medicare All Medicare |
$39.20
|
| Rate for Payer: Monida Allegiance |
$53.20
|
| Rate for Payer: Monida First Choice Health |
$54.32
|
| Rate for Payer: Monida Montana Health Co-op |
$53.20
|
| Rate for Payer: Monida PacificSource |
$53.20
|
|
|
IRRIGATION OF IMPLANTED VENOUS ACCESS TR
|
Facility
|
IP
|
$143.00
|
|
|
Service Code
|
CPT 96523
|
| Hospital Charge Code |
1096523
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$100.10 |
| Max. Negotiated Rate |
$143.00 |
| Rate for Payer: Aetna Commercial |
$135.85
|
| Rate for Payer: Aetna Medicare |
$128.70
|
| Rate for Payer: BCBS MT CHIP |
$128.70
|
| Rate for Payer: BCBS MT Closed Plan Network |
$135.85
|
| Rate for Payer: BCBS MT HealthLink |
$128.70
|
| Rate for Payer: BCBS MT Medicare |
$128.70
|
| Rate for Payer: BCBS MT POS |
$135.85
|
| Rate for Payer: BCBS MT Traditional |
$143.00
|
| Rate for Payer: Cash Price |
$128.70
|
| Rate for Payer: Cigna Commercial |
$135.85
|
| Rate for Payer: Cigna Medicare |
$128.70
|
| Rate for Payer: Medicaid All Medicaid |
$131.56
|
| Rate for Payer: Medicare All Medicare |
$100.10
|
| Rate for Payer: Monida Allegiance |
$135.85
|
| Rate for Payer: Monida First Choice Health |
$138.71
|
| Rate for Payer: Monida Montana Health Co-op |
$135.85
|
| Rate for Payer: Monida PacificSource |
$135.85
|
|
|
IRRIGATION OF IMPLANTED VENOUS ACCESS TR
|
Facility
|
OP
|
$143.00
|
|
|
Service Code
|
CPT 96523
|
| Hospital Charge Code |
1096523
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$100.10 |
| Max. Negotiated Rate |
$143.00 |
| Rate for Payer: Aetna Commercial |
$135.85
|
| Rate for Payer: Aetna Medicare |
$128.70
|
| Rate for Payer: BCBS MT CHIP |
$128.70
|
| Rate for Payer: BCBS MT Closed Plan Network |
$135.85
|
| Rate for Payer: BCBS MT HealthLink |
$128.70
|
| Rate for Payer: BCBS MT Medicare |
$128.70
|
| Rate for Payer: BCBS MT POS |
$135.85
|
| Rate for Payer: BCBS MT Traditional |
$143.00
|
| Rate for Payer: Cash Price |
$128.70
|
| Rate for Payer: Cigna Commercial |
$135.85
|
| Rate for Payer: Cigna Medicare |
$128.70
|
| Rate for Payer: Medicaid All Medicaid |
$131.56
|
| Rate for Payer: Medicare All Medicare |
$100.10
|
| Rate for Payer: Monida Allegiance |
$135.85
|
| Rate for Payer: Monida First Choice Health |
$138.71
|
| Rate for Payer: Monida Montana Health Co-op |
$135.85
|
| Rate for Payer: Monida PacificSource |
$135.85
|
|
|
ISLET CELL CYTOPLASMIC AB IGG
|
Facility
|
IP
|
$120.00
|
|
|
Service Code
|
CPT 86341
|
| Hospital Charge Code |
4088110
|
|
Hospital Revenue Code
|
302
|
| 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
|
|
|
ISLET CELL CYTOPLASMIC AB IGG
|
Facility
|
OP
|
$120.00
|
|
|
Service Code
|
CPT 86341
|
| Hospital Charge Code |
4088110
|
|
Hospital Revenue Code
|
302
|
| 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
|
|
|
ISOSORBIDE DINITRATE TAB [10 MG] NF
|
Facility
|
OP
|
$8.00
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
3000239
|
|
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
|
|
|
ISOSORBIDE DINITRATE TAB [10 MG] NF
|
Facility
|
IP
|
$8.00
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
3000239
|
|
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
|
|
|
ISOSORBIDE MONO ER TAB [30 MG] NF
|
Facility
|
IP
|
$8.00
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
3000240
|
|
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
|
|
|
ISOSORBIDE MONO ER TAB [30 MG] NF
|
Facility
|
OP
|
$8.00
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
3000240
|
|
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
|
|
