|
ARIPIPRAZOLE TAB [2 MG] NF
|
Facility
|
IP
|
$103.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
3000542
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$72.10 |
| Max. Negotiated Rate |
$103.00 |
| Rate for Payer: Aetna Commercial |
$97.85
|
| Rate for Payer: Aetna Medicare |
$92.70
|
| Rate for Payer: BCBS MT CHIP |
$92.70
|
| Rate for Payer: BCBS MT Closed Plan Network |
$97.85
|
| Rate for Payer: BCBS MT HealthLink |
$92.70
|
| Rate for Payer: BCBS MT Medicare |
$92.70
|
| Rate for Payer: BCBS MT POS |
$97.85
|
| Rate for Payer: BCBS MT Traditional |
$103.00
|
| Rate for Payer: Cash Price |
$92.70
|
| Rate for Payer: Cigna Commercial |
$97.85
|
| Rate for Payer: Cigna Medicare |
$92.70
|
| Rate for Payer: Medicaid All Medicaid |
$94.76
|
| Rate for Payer: Medicare All Medicare |
$72.10
|
| Rate for Payer: Monida Allegiance |
$97.85
|
| Rate for Payer: Monida First Choice Health |
$99.91
|
| Rate for Payer: Monida Montana Health Co-op |
$97.85
|
| Rate for Payer: Monida PacificSource |
$97.85
|
|
|
ARIPIPRAZOLE TAB [5 MG] NF
|
Facility
|
IP
|
$108.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
3007069
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$75.60 |
| Max. Negotiated Rate |
$108.00 |
| Rate for Payer: Aetna Commercial |
$102.60
|
| Rate for Payer: Aetna Medicare |
$97.20
|
| Rate for Payer: BCBS MT CHIP |
$97.20
|
| Rate for Payer: BCBS MT Closed Plan Network |
$102.60
|
| Rate for Payer: BCBS MT HealthLink |
$97.20
|
| Rate for Payer: BCBS MT Medicare |
$97.20
|
| Rate for Payer: BCBS MT POS |
$102.60
|
| Rate for Payer: BCBS MT Traditional |
$108.00
|
| Rate for Payer: Cash Price |
$97.20
|
| Rate for Payer: Cigna Commercial |
$102.60
|
| Rate for Payer: Cigna Medicare |
$97.20
|
| Rate for Payer: Medicaid All Medicaid |
$99.36
|
| Rate for Payer: Medicare All Medicare |
$75.60
|
| Rate for Payer: Monida Allegiance |
$102.60
|
| Rate for Payer: Monida First Choice Health |
$104.76
|
| Rate for Payer: Monida Montana Health Co-op |
$102.60
|
| Rate for Payer: Monida PacificSource |
$102.60
|
|
|
ARIPIPRAZOLE TAB [5 MG] NF
|
Facility
|
OP
|
$108.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
3007069
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$75.60 |
| Max. Negotiated Rate |
$108.00 |
| Rate for Payer: Aetna Commercial |
$102.60
|
| Rate for Payer: Aetna Medicare |
$97.20
|
| Rate for Payer: BCBS MT CHIP |
$97.20
|
| Rate for Payer: BCBS MT Closed Plan Network |
$102.60
|
| Rate for Payer: BCBS MT HealthLink |
$97.20
|
| Rate for Payer: BCBS MT Medicare |
$97.20
|
| Rate for Payer: BCBS MT POS |
$102.60
|
| Rate for Payer: BCBS MT Traditional |
$108.00
|
| Rate for Payer: Cash Price |
$97.20
|
| Rate for Payer: Cigna Commercial |
$102.60
|
| Rate for Payer: Cigna Medicare |
$97.20
|
| Rate for Payer: Medicaid All Medicaid |
$99.36
|
| Rate for Payer: Medicare All Medicare |
$75.60
|
| Rate for Payer: Monida Allegiance |
$102.60
|
| Rate for Payer: Monida First Choice Health |
$104.76
|
| Rate for Payer: Monida Montana Health Co-op |
$102.60
|
| Rate for Payer: Monida PacificSource |
$102.60
|
|
|
ARM SLING LG
|
Facility
|
OP
|
$14.00
|
|
| Hospital Charge Code |
2893186
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$9.80 |
| Max. Negotiated Rate |
$14.00 |
| Rate for Payer: Aetna Commercial |
$13.30
|
| Rate for Payer: Aetna Medicare |
$12.60
|
| Rate for Payer: BCBS MT CHIP |
$12.60
|
| Rate for Payer: BCBS MT Closed Plan Network |
$13.30
|
| Rate for Payer: BCBS MT HealthLink |
$12.60
|
| Rate for Payer: BCBS MT Medicare |
$12.60
|
| Rate for Payer: BCBS MT POS |
$13.30
|
| Rate for Payer: BCBS MT Traditional |
$14.00
|
| Rate for Payer: Cash Price |
$12.60
|
| Rate for Payer: Cigna Commercial |
$13.30
|
| Rate for Payer: Cigna Medicare |
$12.60
|
| Rate for Payer: Medicaid All Medicaid |
$12.88
|
| Rate for Payer: Medicare All Medicare |
$9.80
|
| Rate for Payer: Monida Allegiance |
$13.30
|
| Rate for Payer: Monida First Choice Health |
$13.58
|
| Rate for Payer: Monida Montana Health Co-op |
$13.30
|
| Rate for Payer: Monida PacificSource |
$13.30
|
|
|
ARM SLING LG
|
Facility
|
IP
|
$14.00
|
|
| Hospital Charge Code |
2893186
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$9.80 |
| Max. Negotiated Rate |
$14.00 |
| Rate for Payer: Aetna Commercial |
$13.30
|
| Rate for Payer: Aetna Medicare |
$12.60
|
| Rate for Payer: BCBS MT CHIP |
$12.60
|
| Rate for Payer: BCBS MT Closed Plan Network |
$13.30
|
| Rate for Payer: BCBS MT HealthLink |
$12.60
|
| Rate for Payer: BCBS MT Medicare |
$12.60
|
| Rate for Payer: BCBS MT POS |
$13.30
|
| Rate for Payer: BCBS MT Traditional |
$14.00
|
| Rate for Payer: Cash Price |
$12.60
|
| Rate for Payer: Cigna Commercial |
$13.30
|
| Rate for Payer: Cigna Medicare |
$12.60
|
| Rate for Payer: Medicaid All Medicaid |
$12.88
|
| Rate for Payer: Medicare All Medicare |
$9.80
|
| Rate for Payer: Monida Allegiance |
$13.30
|
| Rate for Payer: Monida First Choice Health |
$13.58
|
| Rate for Payer: Monida Montana Health Co-op |
$13.30
|
| Rate for Payer: Monida PacificSource |
$13.30
|
|
|
ARM SLING MED
|
Facility
|
OP
|
$14.00
|
|
| Hospital Charge Code |
2893185
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$9.80 |
| Max. Negotiated Rate |
$14.00 |
| Rate for Payer: Aetna Commercial |
$13.30
|
| Rate for Payer: Aetna Medicare |
$12.60
|
| Rate for Payer: BCBS MT CHIP |
$12.60
|
| Rate for Payer: BCBS MT Closed Plan Network |
$13.30
|
| Rate for Payer: BCBS MT HealthLink |
$12.60
|
| Rate for Payer: BCBS MT Medicare |
$12.60
|
| Rate for Payer: BCBS MT POS |
$13.30
|
| Rate for Payer: BCBS MT Traditional |
$14.00
|
| Rate for Payer: Cash Price |
$12.60
|
| Rate for Payer: Cigna Commercial |
$13.30
|
| Rate for Payer: Cigna Medicare |
$12.60
|
| Rate for Payer: Medicaid All Medicaid |
$12.88
|
| Rate for Payer: Medicare All Medicare |
$9.80
|
| Rate for Payer: Monida Allegiance |
$13.30
|
| Rate for Payer: Monida First Choice Health |
$13.58
|
| Rate for Payer: Monida Montana Health Co-op |
$13.30
|
| Rate for Payer: Monida PacificSource |
$13.30
|
|
|
ARM SLING MED
|
Facility
|
IP
|
$14.00
|
|
| Hospital Charge Code |
2893185
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$9.80 |
| Max. Negotiated Rate |
$14.00 |
| Rate for Payer: Aetna Commercial |
$13.30
|
| Rate for Payer: Aetna Medicare |
$12.60
|
| Rate for Payer: BCBS MT CHIP |
$12.60
|
| Rate for Payer: BCBS MT Closed Plan Network |
$13.30
|
| Rate for Payer: BCBS MT HealthLink |
$12.60
|
| Rate for Payer: BCBS MT Medicare |
$12.60
|
| Rate for Payer: BCBS MT POS |
$13.30
|
| Rate for Payer: BCBS MT Traditional |
$14.00
|
| Rate for Payer: Cash Price |
$12.60
|
| Rate for Payer: Cigna Commercial |
$13.30
|
| Rate for Payer: Cigna Medicare |
$12.60
|
| Rate for Payer: Medicaid All Medicaid |
$12.88
|
| Rate for Payer: Medicare All Medicare |
$9.80
|
| Rate for Payer: Monida Allegiance |
$13.30
|
| Rate for Payer: Monida First Choice Health |
$13.58
|
| Rate for Payer: Monida Montana Health Co-op |
$13.30
|
| Rate for Payer: Monida PacificSource |
$13.30
|
|
|
ARM SLING PEDS
|
Facility
|
IP
|
$15.00
|
|
| Hospital Charge Code |
2893183
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$10.50 |
| Max. Negotiated Rate |
$15.00 |
| Rate for Payer: Aetna Commercial |
$14.25
|
| Rate for Payer: Aetna Medicare |
$13.50
|
| Rate for Payer: BCBS MT CHIP |
$13.50
|
| Rate for Payer: BCBS MT Closed Plan Network |
$14.25
|
| Rate for Payer: BCBS MT HealthLink |
$13.50
|
| Rate for Payer: BCBS MT Medicare |
$13.50
|
| Rate for Payer: BCBS MT POS |
$14.25
|
| Rate for Payer: BCBS MT Traditional |
$15.00
|
| Rate for Payer: Cash Price |
$13.50
|
| Rate for Payer: Cigna Commercial |
$14.25
|
| Rate for Payer: Cigna Medicare |
$13.50
|
| Rate for Payer: Medicaid All Medicaid |
$13.80
|
| Rate for Payer: Medicare All Medicare |
$10.50
|
| Rate for Payer: Monida Allegiance |
$14.25
|
| Rate for Payer: Monida First Choice Health |
$14.55
|
| Rate for Payer: Monida Montana Health Co-op |
$14.25
|
| Rate for Payer: Monida PacificSource |
$14.25
|
|
|
ARM SLING PEDS
|
Facility
|
OP
|
$15.00
|
|
| Hospital Charge Code |
2893183
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$10.50 |
| Max. Negotiated Rate |
$15.00 |
| Rate for Payer: Aetna Commercial |
$14.25
|
| Rate for Payer: Aetna Medicare |
$13.50
|
| Rate for Payer: BCBS MT CHIP |
$13.50
|
| Rate for Payer: BCBS MT Closed Plan Network |
$14.25
|
| Rate for Payer: BCBS MT HealthLink |
$13.50
|
| Rate for Payer: BCBS MT Medicare |
$13.50
|
| Rate for Payer: BCBS MT POS |
$14.25
|
| Rate for Payer: BCBS MT Traditional |
$15.00
|
| Rate for Payer: Cash Price |
$13.50
|
| Rate for Payer: Cigna Commercial |
$14.25
|
| Rate for Payer: Cigna Medicare |
$13.50
|
| Rate for Payer: Medicaid All Medicaid |
$13.80
|
| Rate for Payer: Medicare All Medicare |
$10.50
|
| Rate for Payer: Monida Allegiance |
$14.25
|
| Rate for Payer: Monida First Choice Health |
$14.55
|
| Rate for Payer: Monida Montana Health Co-op |
$14.25
|
| Rate for Payer: Monida PacificSource |
$14.25
|
|
|
ARM SLING PEDS /XS
|
Facility
|
OP
|
$18.00
|
|
| Hospital Charge Code |
2820004
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$12.60 |
| Max. Negotiated Rate |
$18.00 |
| Rate for Payer: Aetna Commercial |
$17.10
|
| Rate for Payer: Aetna Medicare |
$16.20
|
| Rate for Payer: BCBS MT CHIP |
$16.20
|
| Rate for Payer: BCBS MT Closed Plan Network |
$17.10
|
| Rate for Payer: BCBS MT HealthLink |
$16.20
|
| Rate for Payer: BCBS MT Medicare |
$16.20
|
| Rate for Payer: BCBS MT POS |
$17.10
|
| Rate for Payer: BCBS MT Traditional |
$18.00
|
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Cigna Commercial |
$17.10
|
| Rate for Payer: Cigna Medicare |
$16.20
|
| Rate for Payer: Medicaid All Medicaid |
$16.56
|
| Rate for Payer: Medicare All Medicare |
$12.60
|
| Rate for Payer: Monida Allegiance |
$17.10
|
| Rate for Payer: Monida First Choice Health |
$17.46
|
| Rate for Payer: Monida Montana Health Co-op |
$17.10
|
| Rate for Payer: Monida PacificSource |
$17.10
|
|
|
ARM SLING PEDS /XS
|
Facility
|
IP
|
$18.00
|
|
| Hospital Charge Code |
2820004
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$12.60 |
| Max. Negotiated Rate |
$18.00 |
| Rate for Payer: Aetna Commercial |
$17.10
|
| Rate for Payer: Aetna Medicare |
$16.20
|
| Rate for Payer: BCBS MT CHIP |
$16.20
|
| Rate for Payer: BCBS MT Closed Plan Network |
$17.10
|
| Rate for Payer: BCBS MT HealthLink |
$16.20
|
| Rate for Payer: BCBS MT Medicare |
$16.20
|
| Rate for Payer: BCBS MT POS |
$17.10
|
| Rate for Payer: BCBS MT Traditional |
$18.00
|
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Cigna Commercial |
$17.10
|
| Rate for Payer: Cigna Medicare |
$16.20
|
| Rate for Payer: Medicaid All Medicaid |
$16.56
|
| Rate for Payer: Medicare All Medicare |
$12.60
|
| Rate for Payer: Monida Allegiance |
$17.10
|
| Rate for Payer: Monida First Choice Health |
$17.46
|
| Rate for Payer: Monida Montana Health Co-op |
$17.10
|
| Rate for Payer: Monida PacificSource |
$17.10
|
|
|
ARM SLING SM
|
Facility
|
OP
|
$14.00
|
|
| Hospital Charge Code |
2893184
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$9.80 |
| Max. Negotiated Rate |
$14.00 |
| Rate for Payer: Aetna Commercial |
$13.30
|
| Rate for Payer: Aetna Medicare |
$12.60
|
| Rate for Payer: BCBS MT CHIP |
$12.60
|
| Rate for Payer: BCBS MT Closed Plan Network |
$13.30
|
| Rate for Payer: BCBS MT HealthLink |
$12.60
|
| Rate for Payer: BCBS MT Medicare |
$12.60
|
| Rate for Payer: BCBS MT POS |
$13.30
|
| Rate for Payer: BCBS MT Traditional |
$14.00
|
| Rate for Payer: Cash Price |
$12.60
|
| Rate for Payer: Cigna Commercial |
$13.30
|
| Rate for Payer: Cigna Medicare |
$12.60
|
| Rate for Payer: Medicaid All Medicaid |
$12.88
|
| Rate for Payer: Medicare All Medicare |
$9.80
|
| Rate for Payer: Monida Allegiance |
$13.30
|
| Rate for Payer: Monida First Choice Health |
$13.58
|
| Rate for Payer: Monida Montana Health Co-op |
$13.30
|
| Rate for Payer: Monida PacificSource |
$13.30
|
|
|
ARM SLING SM
|
Facility
|
IP
|
$14.00
|
|
| Hospital Charge Code |
2893184
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$9.80 |
| Max. Negotiated Rate |
$14.00 |
| Rate for Payer: Aetna Commercial |
$13.30
|
| Rate for Payer: Aetna Medicare |
$12.60
|
| Rate for Payer: BCBS MT CHIP |
$12.60
|
| Rate for Payer: BCBS MT Closed Plan Network |
$13.30
|
| Rate for Payer: BCBS MT HealthLink |
$12.60
|
| Rate for Payer: BCBS MT Medicare |
$12.60
|
| Rate for Payer: BCBS MT POS |
$13.30
|
| Rate for Payer: BCBS MT Traditional |
$14.00
|
| Rate for Payer: Cash Price |
$12.60
|
| Rate for Payer: Cigna Commercial |
$13.30
|
| Rate for Payer: Cigna Medicare |
$12.60
|
| Rate for Payer: Medicaid All Medicaid |
$12.88
|
| Rate for Payer: Medicare All Medicare |
$9.80
|
| Rate for Payer: Monida Allegiance |
$13.30
|
| Rate for Payer: Monida First Choice Health |
$13.58
|
| Rate for Payer: Monida Montana Health Co-op |
$13.30
|
| Rate for Payer: Monida PacificSource |
$13.30
|
|
|
ARM SLING XL
|
Facility
|
OP
|
$14.00
|
|
| Hospital Charge Code |
2893187
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$9.80 |
| Max. Negotiated Rate |
$14.00 |
| Rate for Payer: Aetna Commercial |
$13.30
|
| Rate for Payer: Aetna Medicare |
$12.60
|
| Rate for Payer: BCBS MT CHIP |
$12.60
|
| Rate for Payer: BCBS MT Closed Plan Network |
$13.30
|
| Rate for Payer: BCBS MT HealthLink |
$12.60
|
| Rate for Payer: BCBS MT Medicare |
$12.60
|
| Rate for Payer: BCBS MT POS |
$13.30
|
| Rate for Payer: BCBS MT Traditional |
$14.00
|
| Rate for Payer: Cash Price |
$12.60
|
| Rate for Payer: Cigna Commercial |
$13.30
|
| Rate for Payer: Cigna Medicare |
$12.60
|
| Rate for Payer: Medicaid All Medicaid |
$12.88
|
| Rate for Payer: Medicare All Medicare |
$9.80
|
| Rate for Payer: Monida Allegiance |
$13.30
|
| Rate for Payer: Monida First Choice Health |
$13.58
|
| Rate for Payer: Monida Montana Health Co-op |
$13.30
|
| Rate for Payer: Monida PacificSource |
$13.30
|
|
|
ARM SLING XL
|
Facility
|
IP
|
$14.00
|
|
| Hospital Charge Code |
2893187
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$9.80 |
| Max. Negotiated Rate |
$14.00 |
| Rate for Payer: Aetna Commercial |
$13.30
|
| Rate for Payer: Aetna Medicare |
$12.60
|
| Rate for Payer: BCBS MT CHIP |
$12.60
|
| Rate for Payer: BCBS MT Closed Plan Network |
$13.30
|
| Rate for Payer: BCBS MT HealthLink |
$12.60
|
| Rate for Payer: BCBS MT Medicare |
$12.60
|
| Rate for Payer: BCBS MT POS |
$13.30
|
| Rate for Payer: BCBS MT Traditional |
$14.00
|
| Rate for Payer: Cash Price |
$12.60
|
| Rate for Payer: Cigna Commercial |
$13.30
|
| Rate for Payer: Cigna Medicare |
$12.60
|
| Rate for Payer: Medicaid All Medicaid |
$12.88
|
| Rate for Payer: Medicare All Medicare |
$9.80
|
| Rate for Payer: Monida Allegiance |
$13.30
|
| Rate for Payer: Monida First Choice Health |
$13.58
|
| Rate for Payer: Monida Montana Health Co-op |
$13.30
|
| Rate for Payer: Monida PacificSource |
$13.30
|
|
|
.ARTERIAL PUNCTURE
|
Facility
|
IP
|
$177.00
|
|
|
Service Code
|
HCPCS 36600
|
| Hospital Charge Code |
4000078
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$123.90 |
| Max. Negotiated Rate |
$177.00 |
| Rate for Payer: Aetna Commercial |
$168.15
|
| Rate for Payer: Aetna Medicare |
$159.30
|
| Rate for Payer: BCBS MT CHIP |
$159.30
|
| Rate for Payer: BCBS MT Closed Plan Network |
$168.15
|
| Rate for Payer: BCBS MT HealthLink |
$159.30
|
| Rate for Payer: BCBS MT Medicare |
$159.30
|
| Rate for Payer: BCBS MT POS |
$168.15
|
| Rate for Payer: BCBS MT Traditional |
$177.00
|
| Rate for Payer: Cash Price |
$159.30
|
| Rate for Payer: Cigna Commercial |
$168.15
|
| Rate for Payer: Cigna Medicare |
$159.30
|
| Rate for Payer: Medicaid All Medicaid |
$162.84
|
| Rate for Payer: Medicare All Medicare |
$123.90
|
| Rate for Payer: Monida Allegiance |
$168.15
|
| Rate for Payer: Monida First Choice Health |
$171.69
|
| Rate for Payer: Monida Montana Health Co-op |
$168.15
|
| Rate for Payer: Monida PacificSource |
$168.15
|
|
|
.ARTERIAL PUNCTURE
|
Facility
|
OP
|
$177.00
|
|
|
Service Code
|
HCPCS 36600
|
| Hospital Charge Code |
4000078
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$123.90 |
| Max. Negotiated Rate |
$177.00 |
| Rate for Payer: Aetna Commercial |
$168.15
|
| Rate for Payer: Aetna Medicare |
$159.30
|
| Rate for Payer: BCBS MT CHIP |
$159.30
|
| Rate for Payer: BCBS MT Closed Plan Network |
$168.15
|
| Rate for Payer: BCBS MT HealthLink |
$159.30
|
| Rate for Payer: BCBS MT Medicare |
$159.30
|
| Rate for Payer: BCBS MT POS |
$168.15
|
| Rate for Payer: BCBS MT Traditional |
$177.00
|
| Rate for Payer: Cash Price |
$159.30
|
| Rate for Payer: Cigna Commercial |
$168.15
|
| Rate for Payer: Cigna Medicare |
$159.30
|
| Rate for Payer: Medicaid All Medicaid |
$162.84
|
| Rate for Payer: Medicare All Medicare |
$123.90
|
| Rate for Payer: Monida Allegiance |
$168.15
|
| Rate for Payer: Monida First Choice Health |
$171.69
|
| Rate for Payer: Monida Montana Health Co-op |
$168.15
|
| Rate for Payer: Monida PacificSource |
$168.15
|
|
|
ASO ANTIBODIES (006031)
|
Facility
|
IP
|
$24.00
|
|
|
Service Code
|
HCPCS 86060
|
| Hospital Charge Code |
4086060
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$16.80 |
| Max. Negotiated Rate |
$24.00 |
| Rate for Payer: Aetna Commercial |
$22.80
|
| Rate for Payer: Aetna Medicare |
$21.60
|
| Rate for Payer: BCBS MT CHIP |
$21.60
|
| Rate for Payer: BCBS MT Closed Plan Network |
$22.80
|
| Rate for Payer: BCBS MT HealthLink |
$21.60
|
| Rate for Payer: BCBS MT Medicare |
$21.60
|
| Rate for Payer: BCBS MT POS |
$22.80
|
| Rate for Payer: BCBS MT Traditional |
$24.00
|
| Rate for Payer: Cash Price |
$21.60
|
| Rate for Payer: Cigna Commercial |
$22.80
|
| Rate for Payer: Cigna Medicare |
$21.60
|
| Rate for Payer: Medicaid All Medicaid |
$22.08
|
| Rate for Payer: Medicare All Medicare |
$16.80
|
| Rate for Payer: Monida Allegiance |
$22.80
|
| Rate for Payer: Monida First Choice Health |
$23.28
|
| Rate for Payer: Monida Montana Health Co-op |
$22.80
|
| Rate for Payer: Monida PacificSource |
$22.80
|
|
|
ASO ANTIBODIES (006031)
|
Facility
|
OP
|
$24.00
|
|
|
Service Code
|
HCPCS 86060
|
| Hospital Charge Code |
4086060
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$16.80 |
| Max. Negotiated Rate |
$24.00 |
| Rate for Payer: Aetna Commercial |
$22.80
|
| Rate for Payer: Aetna Medicare |
$21.60
|
| Rate for Payer: BCBS MT CHIP |
$21.60
|
| Rate for Payer: BCBS MT Closed Plan Network |
$22.80
|
| Rate for Payer: BCBS MT HealthLink |
$21.60
|
| Rate for Payer: BCBS MT Medicare |
$21.60
|
| Rate for Payer: BCBS MT POS |
$22.80
|
| Rate for Payer: BCBS MT Traditional |
$24.00
|
| Rate for Payer: Cash Price |
$21.60
|
| Rate for Payer: Cigna Commercial |
$22.80
|
| Rate for Payer: Cigna Medicare |
$21.60
|
| Rate for Payer: Medicaid All Medicaid |
$22.08
|
| Rate for Payer: Medicare All Medicare |
$16.80
|
| Rate for Payer: Monida Allegiance |
$22.80
|
| Rate for Payer: Monida First Choice Health |
$23.28
|
| Rate for Payer: Monida Montana Health Co-op |
$22.80
|
| Rate for Payer: Monida PacificSource |
$22.80
|
|
|
ASPIRIN CHEW TAB [81 MG]
|
Facility
|
OP
|
$8.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
3000036
|
|
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
|
|
|
ASPIRIN CHEW TAB [81 MG]
|
Facility
|
IP
|
$8.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
3000036
|
|
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
|
|
|
ASPIRIN EC TAB [81 MG]
|
Facility
|
IP
|
$8.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
3000037
|
|
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
|
|
|
ASPIRIN EC TAB [81 MG]
|
Facility
|
OP
|
$8.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
3000037
|
|
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
|
|
|
ASPIRIN TAB [325 MG]
|
Facility
|
OP
|
$8.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
3000038
|
|
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
|
|
|
ASPIRIN TAB [325 MG]
|
Facility
|
IP
|
$8.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
3000038
|
|
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
|
|
