|
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
|
|
|
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
|
|
|
MASSAGE (PERCUSSION) PER 15
|
Facility
|
OP
|
$87.00
|
|
|
Service Code
|
CPT 97124
|
| Hospital Charge Code |
8197124
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$60.90 |
| Max. Negotiated Rate |
$87.00 |
| Rate for Payer: Aetna Commercial |
$82.65
|
| Rate for Payer: Aetna Medicare |
$78.30
|
| Rate for Payer: BCBS MT CHIP |
$78.30
|
| Rate for Payer: BCBS MT Closed Plan Network |
$82.65
|
| Rate for Payer: BCBS MT HealthLink |
$78.30
|
| Rate for Payer: BCBS MT Medicare |
$78.30
|
| Rate for Payer: BCBS MT POS |
$82.65
|
| Rate for Payer: BCBS MT Traditional |
$87.00
|
| Rate for Payer: Cash Price |
$78.30
|
| Rate for Payer: Cigna Commercial |
$82.65
|
| Rate for Payer: Cigna Medicare |
$78.30
|
| Rate for Payer: Medicaid All Medicaid |
$80.04
|
| Rate for Payer: Medicare All Medicare |
$60.90
|
| Rate for Payer: Monida Allegiance |
$82.65
|
| Rate for Payer: Monida First Choice Health |
$84.39
|
| Rate for Payer: Monida Montana Health Co-op |
$82.65
|
| Rate for Payer: Monida PacificSource |
$82.65
|
|
|
MASSAGE (PERCUSSION) PER 15
|
Facility
|
IP
|
$87.00
|
|
|
Service Code
|
CPT 97124
|
| Hospital Charge Code |
8197124
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$60.90 |
| Max. Negotiated Rate |
$87.00 |
| Rate for Payer: Aetna Commercial |
$82.65
|
| Rate for Payer: Aetna Medicare |
$78.30
|
| Rate for Payer: BCBS MT CHIP |
$78.30
|
| Rate for Payer: BCBS MT Closed Plan Network |
$82.65
|
| Rate for Payer: BCBS MT HealthLink |
$78.30
|
| Rate for Payer: BCBS MT Medicare |
$78.30
|
| Rate for Payer: BCBS MT POS |
$82.65
|
| Rate for Payer: BCBS MT Traditional |
$87.00
|
| Rate for Payer: Cash Price |
$78.30
|
| Rate for Payer: Cigna Commercial |
$82.65
|
| Rate for Payer: Cigna Medicare |
$78.30
|
| Rate for Payer: Medicaid All Medicaid |
$80.04
|
| Rate for Payer: Medicare All Medicare |
$60.90
|
| Rate for Payer: Monida Allegiance |
$82.65
|
| Rate for Payer: Monida First Choice Health |
$84.39
|
| Rate for Payer: Monida Montana Health Co-op |
$82.65
|
| Rate for Payer: Monida PacificSource |
$82.65
|
|
|
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
|
|
|
MAXORB ALGINATE DRESSING MSC94
|
Facility
|
OP
|
$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
|
|
|
MCKESSON WINGED SAFETY NEEDLE
|
Facility
|
IP
|
$41.24
|
|
| Hospital Charge Code |
90195272
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$28.87 |
| Max. Negotiated Rate |
$41.24 |
| Rate for Payer: Aetna Commercial |
$39.18
|
| Rate for Payer: Aetna Medicare |
$37.12
|
| Rate for Payer: BCBS MT CHIP |
$37.12
|
| Rate for Payer: BCBS MT Closed Plan Network |
$39.18
|
| Rate for Payer: BCBS MT HealthLink |
$37.12
|
| Rate for Payer: BCBS MT Medicare |
$37.12
|
| Rate for Payer: BCBS MT POS |
$39.18
|
| Rate for Payer: BCBS MT Traditional |
$41.24
|
| Rate for Payer: Cash Price |
$37.12
|
| Rate for Payer: Cigna Commercial |
$39.18
|
| Rate for Payer: Cigna Medicare |
$37.12
|
| Rate for Payer: Medicaid All Medicaid |
$37.94
|
| Rate for Payer: Medicare All Medicare |
$28.87
|
| Rate for Payer: Monida Allegiance |
$39.18
|
| Rate for Payer: Monida First Choice Health |
$40.00
|
| Rate for Payer: Monida Montana Health Co-op |
$39.18
|
| Rate for Payer: Monida PacificSource |
$39.18
|
|
|
MCKESSON WINGED SAFETY NEEDLE
|
Facility
|
OP
|
$41.24
|
|
| Hospital Charge Code |
90195272
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$28.87 |
| Max. Negotiated Rate |
$41.24 |
| Rate for Payer: Aetna Commercial |
$39.18
|
| Rate for Payer: Aetna Medicare |
$37.12
|
| Rate for Payer: BCBS MT CHIP |
$37.12
|
| Rate for Payer: BCBS MT Closed Plan Network |
$39.18
|
| Rate for Payer: BCBS MT HealthLink |
$37.12
|
| Rate for Payer: BCBS MT Medicare |
$37.12
|
| Rate for Payer: BCBS MT POS |
$39.18
|
| Rate for Payer: BCBS MT Traditional |
$41.24
|
| Rate for Payer: Cash Price |
$37.12
|
| Rate for Payer: Cigna Commercial |
$39.18
|
| Rate for Payer: Cigna Medicare |
$37.12
|
| Rate for Payer: Medicaid All Medicaid |
$37.94
|
| Rate for Payer: Medicare All Medicare |
$28.87
|
| Rate for Payer: Monida Allegiance |
$39.18
|
| Rate for Payer: Monida First Choice Health |
$40.00
|
| Rate for Payer: Monida Montana Health Co-op |
$39.18
|
| Rate for Payer: Monida PacificSource |
$39.18
|
|
|
MEASLES AB, IGG (096560)
|
Facility
|
OP
|
$69.00
|
|
|
Service Code
|
CPT 86765
|
| Hospital Charge Code |
4086765
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$48.30 |
| Max. Negotiated Rate |
$69.00 |
| Rate for Payer: Aetna Commercial |
$65.55
|
| Rate for Payer: Aetna Medicare |
$62.10
|
| Rate for Payer: BCBS MT CHIP |
$62.10
|
| Rate for Payer: BCBS MT Closed Plan Network |
$65.55
|
| Rate for Payer: BCBS MT HealthLink |
$62.10
|
| Rate for Payer: BCBS MT Medicare |
$62.10
|
| Rate for Payer: BCBS MT POS |
$65.55
|
| Rate for Payer: BCBS MT Traditional |
$69.00
|
| Rate for Payer: Cash Price |
$62.10
|
| Rate for Payer: Cigna Commercial |
$65.55
|
| Rate for Payer: Cigna Medicare |
$62.10
|
| Rate for Payer: Medicaid All Medicaid |
$63.48
|
| Rate for Payer: Medicare All Medicare |
$48.30
|
| Rate for Payer: Monida Allegiance |
$65.55
|
| Rate for Payer: Monida First Choice Health |
$66.93
|
| Rate for Payer: Monida Montana Health Co-op |
$65.55
|
| Rate for Payer: Monida PacificSource |
$65.55
|
|
|
MEASLES AB, IGG (096560)
|
Facility
|
IP
|
$69.00
|
|
|
Service Code
|
CPT 86765
|
| Hospital Charge Code |
4086765
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$48.30 |
| Max. Negotiated Rate |
$69.00 |
| Rate for Payer: Aetna Commercial |
$65.55
|
| Rate for Payer: Aetna Medicare |
$62.10
|
| Rate for Payer: BCBS MT CHIP |
$62.10
|
| Rate for Payer: BCBS MT Closed Plan Network |
$65.55
|
| Rate for Payer: BCBS MT HealthLink |
$62.10
|
| Rate for Payer: BCBS MT Medicare |
$62.10
|
| Rate for Payer: BCBS MT POS |
$65.55
|
| Rate for Payer: BCBS MT Traditional |
$69.00
|
| Rate for Payer: Cash Price |
$62.10
|
| Rate for Payer: Cigna Commercial |
$65.55
|
| Rate for Payer: Cigna Medicare |
$62.10
|
| Rate for Payer: Medicaid All Medicaid |
$63.48
|
| Rate for Payer: Medicare All Medicare |
$48.30
|
| Rate for Payer: Monida Allegiance |
$65.55
|
| Rate for Payer: Monida First Choice Health |
$66.93
|
| Rate for Payer: Monida Montana Health Co-op |
$65.55
|
| Rate for Payer: Monida PacificSource |
$65.55
|
|
|
MEASLES PCR (RUBEOLA)
|
Facility
|
OP
|
$250.00
|
|
|
Service Code
|
CPT 83003
|
| Hospital Charge Code |
4088021
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$175.00 |
| Max. Negotiated Rate |
$250.00 |
| Rate for Payer: Aetna Commercial |
$237.50
|
| Rate for Payer: Aetna Medicare |
$225.00
|
| Rate for Payer: BCBS MT CHIP |
$225.00
|
| Rate for Payer: BCBS MT Closed Plan Network |
$237.50
|
| Rate for Payer: BCBS MT HealthLink |
$225.00
|
| Rate for Payer: BCBS MT Medicare |
$225.00
|
| Rate for Payer: BCBS MT POS |
$237.50
|
| Rate for Payer: BCBS MT Traditional |
$250.00
|
| Rate for Payer: Cash Price |
$225.00
|
| Rate for Payer: Cigna Commercial |
$237.50
|
| Rate for Payer: Cigna Medicare |
$225.00
|
| Rate for Payer: Medicaid All Medicaid |
$230.00
|
| Rate for Payer: Medicare All Medicare |
$175.00
|
| Rate for Payer: Monida Allegiance |
$237.50
|
| Rate for Payer: Monida First Choice Health |
$242.50
|
| Rate for Payer: Monida Montana Health Co-op |
$237.50
|
| Rate for Payer: Monida PacificSource |
$237.50
|
|
|
MEASLES PCR (RUBEOLA)
|
Facility
|
IP
|
$250.00
|
|
|
Service Code
|
CPT 83003
|
| Hospital Charge Code |
4088021
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$175.00 |
| Max. Negotiated Rate |
$250.00 |
| Rate for Payer: Aetna Commercial |
$237.50
|
| Rate for Payer: Aetna Medicare |
$225.00
|
| Rate for Payer: BCBS MT CHIP |
$225.00
|
| Rate for Payer: BCBS MT Closed Plan Network |
$237.50
|
| Rate for Payer: BCBS MT HealthLink |
$225.00
|
| Rate for Payer: BCBS MT Medicare |
$225.00
|
| Rate for Payer: BCBS MT POS |
$237.50
|
| Rate for Payer: BCBS MT Traditional |
$250.00
|
| Rate for Payer: Cash Price |
$225.00
|
| Rate for Payer: Cigna Commercial |
$237.50
|
| Rate for Payer: Cigna Medicare |
$225.00
|
| Rate for Payer: Medicaid All Medicaid |
$230.00
|
| Rate for Payer: Medicare All Medicare |
$175.00
|
| Rate for Payer: Monida Allegiance |
$237.50
|
| Rate for Payer: Monida First Choice Health |
$242.50
|
| Rate for Payer: Monida Montana Health Co-op |
$237.50
|
| Rate for Payer: Monida PacificSource |
$237.50
|
|
|
MEASLES RUBEOLA AB IGM
|
Facility
|
IP
|
$95.00
|
|
|
Service Code
|
CPT 86765
|
| Hospital Charge Code |
4088087
|
|
Hospital Revenue Code
|
302
|
| 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
|
|
|
MEASLES RUBEOLA AB IGM
|
Facility
|
OP
|
$95.00
|
|
|
Service Code
|
CPT 86765
|
| Hospital Charge Code |
4088087
|
|
Hospital Revenue Code
|
302
|
| 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
|
|
|
MECLIZINE TAB [12.5 MG]
|
Facility
|
OP
|
$8.00
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
3000305
|
|
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
|
|
|
MECLIZINE TAB [12.5 MG]
|
Facility
|
IP
|
$8.00
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
3000305
|
|
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
|
|
|
MEDICARE ANNUAL WELLNESS, INITIAL VISIT
|
Facility
|
OP
|
$372.00
|
|
|
Service Code
|
HCPCS G0438
|
| Hospital Charge Code |
8000438
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$260.40 |
| Max. Negotiated Rate |
$372.00 |
| Rate for Payer: Aetna Commercial |
$353.40
|
| Rate for Payer: Aetna Medicare |
$334.80
|
| Rate for Payer: BCBS MT CHIP |
$334.80
|
| Rate for Payer: BCBS MT Closed Plan Network |
$353.40
|
| Rate for Payer: BCBS MT HealthLink |
$334.80
|
| Rate for Payer: BCBS MT Medicare |
$334.80
|
| Rate for Payer: BCBS MT POS |
$353.40
|
| Rate for Payer: BCBS MT Traditional |
$372.00
|
| Rate for Payer: Cash Price |
$334.80
|
| Rate for Payer: Cigna Commercial |
$353.40
|
| Rate for Payer: Cigna Medicare |
$334.80
|
| Rate for Payer: Medicaid All Medicaid |
$342.24
|
| Rate for Payer: Medicare All Medicare |
$260.40
|
| Rate for Payer: Monida Allegiance |
$353.40
|
| Rate for Payer: Monida First Choice Health |
$360.84
|
| Rate for Payer: Monida Montana Health Co-op |
$353.40
|
| Rate for Payer: Monida PacificSource |
$353.40
|
|
|
MEDICARE ANNUAL WELLNESS, INITIAL VISIT
|
Facility
|
IP
|
$372.00
|
|
|
Service Code
|
HCPCS G0438
|
| Hospital Charge Code |
8000438
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$260.40 |
| Max. Negotiated Rate |
$372.00 |
| Rate for Payer: Aetna Commercial |
$353.40
|
| Rate for Payer: Aetna Medicare |
$334.80
|
| Rate for Payer: BCBS MT CHIP |
$334.80
|
| Rate for Payer: BCBS MT Closed Plan Network |
$353.40
|
| Rate for Payer: BCBS MT HealthLink |
$334.80
|
| Rate for Payer: BCBS MT Medicare |
$334.80
|
| Rate for Payer: BCBS MT POS |
$353.40
|
| Rate for Payer: BCBS MT Traditional |
$372.00
|
| Rate for Payer: Cash Price |
$334.80
|
| Rate for Payer: Cigna Commercial |
$353.40
|
| Rate for Payer: Cigna Medicare |
$334.80
|
| Rate for Payer: Medicaid All Medicaid |
$342.24
|
| Rate for Payer: Medicare All Medicare |
$260.40
|
| Rate for Payer: Monida Allegiance |
$353.40
|
| Rate for Payer: Monida First Choice Health |
$360.84
|
| Rate for Payer: Monida Montana Health Co-op |
$353.40
|
| Rate for Payer: Monida PacificSource |
$353.40
|
|
|
MEDICARE ANNUAL WELLNESS VISIT, SUBSEQ
|
Facility
|
OP
|
$311.00
|
|
|
Service Code
|
HCPCS G0439
|
| Hospital Charge Code |
8000439
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$217.70 |
| Max. Negotiated Rate |
$311.00 |
| Rate for Payer: Aetna Commercial |
$295.45
|
| Rate for Payer: Aetna Medicare |
$279.90
|
| Rate for Payer: BCBS MT CHIP |
$279.90
|
| Rate for Payer: BCBS MT Closed Plan Network |
$295.45
|
| Rate for Payer: BCBS MT HealthLink |
$279.90
|
| Rate for Payer: BCBS MT Medicare |
$279.90
|
| Rate for Payer: BCBS MT POS |
$295.45
|
| Rate for Payer: BCBS MT Traditional |
$311.00
|
| Rate for Payer: Cash Price |
$279.90
|
| Rate for Payer: Cigna Commercial |
$295.45
|
| Rate for Payer: Cigna Medicare |
$279.90
|
| Rate for Payer: Medicaid All Medicaid |
$286.12
|
| Rate for Payer: Medicare All Medicare |
$217.70
|
| Rate for Payer: Monida Allegiance |
$295.45
|
| Rate for Payer: Monida First Choice Health |
$301.67
|
| Rate for Payer: Monida Montana Health Co-op |
$295.45
|
| Rate for Payer: Monida PacificSource |
$295.45
|
|
|
MEDICARE ANNUAL WELLNESS VISIT, SUBSEQ
|
Facility
|
IP
|
$311.00
|
|
|
Service Code
|
HCPCS G0439
|
| Hospital Charge Code |
8000439
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$217.70 |
| Max. Negotiated Rate |
$311.00 |
| Rate for Payer: Aetna Commercial |
$295.45
|
| Rate for Payer: Aetna Medicare |
$279.90
|
| Rate for Payer: BCBS MT CHIP |
$279.90
|
| Rate for Payer: BCBS MT Closed Plan Network |
$295.45
|
| Rate for Payer: BCBS MT HealthLink |
$279.90
|
| Rate for Payer: BCBS MT Medicare |
$279.90
|
| Rate for Payer: BCBS MT POS |
$295.45
|
| Rate for Payer: BCBS MT Traditional |
$311.00
|
| Rate for Payer: Cash Price |
$279.90
|
| Rate for Payer: Cigna Commercial |
$295.45
|
| Rate for Payer: Cigna Medicare |
$279.90
|
| Rate for Payer: Medicaid All Medicaid |
$286.12
|
| Rate for Payer: Medicare All Medicare |
$217.70
|
| Rate for Payer: Monida Allegiance |
$295.45
|
| Rate for Payer: Monida First Choice Health |
$301.67
|
| Rate for Payer: Monida Montana Health Co-op |
$295.45
|
| Rate for Payer: Monida PacificSource |
$295.45
|
|
|
MEDICARE DISTANCE SITE TELEHEALTH/PHONE
|
Facility
|
IP
|
$145.00
|
|
|
Service Code
|
HCPCS G2025
|
| Hospital Charge Code |
8002025
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$101.50 |
| Max. Negotiated Rate |
$145.00 |
| Rate for Payer: Aetna Commercial |
$137.75
|
| Rate for Payer: Aetna Medicare |
$130.50
|
| Rate for Payer: BCBS MT CHIP |
$130.50
|
| Rate for Payer: BCBS MT Closed Plan Network |
$137.75
|
| Rate for Payer: BCBS MT HealthLink |
$130.50
|
| Rate for Payer: BCBS MT Medicare |
$130.50
|
| Rate for Payer: BCBS MT POS |
$137.75
|
| Rate for Payer: BCBS MT Traditional |
$145.00
|
| Rate for Payer: Cash Price |
$130.50
|
| Rate for Payer: Cigna Commercial |
$137.75
|
| Rate for Payer: Cigna Medicare |
$130.50
|
| Rate for Payer: Medicaid All Medicaid |
$133.40
|
| Rate for Payer: Medicare All Medicare |
$101.50
|
| Rate for Payer: Monida Allegiance |
$137.75
|
| Rate for Payer: Monida First Choice Health |
$140.65
|
| Rate for Payer: Monida Montana Health Co-op |
$137.75
|
| Rate for Payer: Monida PacificSource |
$137.75
|
|
|
MEDICARE DISTANCE SITE TELEHEALTH/PHONE
|
Facility
|
OP
|
$145.00
|
|
|
Service Code
|
HCPCS G2025
|
| Hospital Charge Code |
8002025
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$101.50 |
| Max. Negotiated Rate |
$145.00 |
| Rate for Payer: Aetna Commercial |
$137.75
|
| Rate for Payer: Aetna Medicare |
$130.50
|
| Rate for Payer: BCBS MT CHIP |
$130.50
|
| Rate for Payer: BCBS MT Closed Plan Network |
$137.75
|
| Rate for Payer: BCBS MT HealthLink |
$130.50
|
| Rate for Payer: BCBS MT Medicare |
$130.50
|
| Rate for Payer: BCBS MT POS |
$137.75
|
| Rate for Payer: BCBS MT Traditional |
$145.00
|
| Rate for Payer: Cash Price |
$130.50
|
| Rate for Payer: Cigna Commercial |
$137.75
|
| Rate for Payer: Cigna Medicare |
$130.50
|
| Rate for Payer: Medicaid All Medicaid |
$133.40
|
| Rate for Payer: Medicare All Medicare |
$101.50
|
| Rate for Payer: Monida Allegiance |
$137.75
|
| Rate for Payer: Monida First Choice Health |
$140.65
|
| Rate for Payer: Monida Montana Health Co-op |
$137.75
|
| Rate for Payer: Monida PacificSource |
$137.75
|
|
|
MEDICATION REVIEW DOCUMENTED
|
Facility
|
IP
|
$0.01
|
|
|
Service Code
|
CPT 1159F
|
| Hospital Charge Code |
8001159
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Aetna Commercial |
$0.01
|
| Rate for Payer: Aetna Medicare |
$0.01
|
| Rate for Payer: BCBS MT CHIP |
$0.01
|
| Rate for Payer: BCBS MT Closed Plan Network |
$0.01
|
| Rate for Payer: BCBS MT HealthLink |
$0.01
|
| Rate for Payer: BCBS MT Medicare |
$0.01
|
| Rate for Payer: BCBS MT POS |
$0.01
|
| Rate for Payer: BCBS MT Traditional |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cigna Commercial |
$0.01
|
| Rate for Payer: Cigna Medicare |
$0.01
|
| Rate for Payer: Medicaid All Medicaid |
$0.01
|
| Rate for Payer: Medicare All Medicare |
$0.01
|
| Rate for Payer: Monida Allegiance |
$0.01
|
| Rate for Payer: Monida First Choice Health |
$0.01
|
| Rate for Payer: Monida Montana Health Co-op |
$0.01
|
| Rate for Payer: Monida PacificSource |
$0.01
|
|
|
MEDICATION REVIEW DOCUMENTED
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
CPT 1159F
|
| Hospital Charge Code |
8001159
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Aetna Commercial |
$0.01
|
| Rate for Payer: Aetna Medicare |
$0.01
|
| Rate for Payer: BCBS MT CHIP |
$0.01
|
| Rate for Payer: BCBS MT Closed Plan Network |
$0.01
|
| Rate for Payer: BCBS MT HealthLink |
$0.01
|
| Rate for Payer: BCBS MT Medicare |
$0.01
|
| Rate for Payer: BCBS MT POS |
$0.01
|
| Rate for Payer: BCBS MT Traditional |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cigna Commercial |
$0.01
|
| Rate for Payer: Cigna Medicare |
$0.01
|
| Rate for Payer: Medicaid All Medicaid |
$0.01
|
| Rate for Payer: Medicare All Medicare |
$0.01
|
| Rate for Payer: Monida Allegiance |
$0.01
|
| Rate for Payer: Monida First Choice Health |
$0.01
|
| Rate for Payer: Monida Montana Health Co-op |
$0.01
|
| Rate for Payer: Monida PacificSource |
$0.01
|
|
|
MEGESTROL TAB [40 MG] NF
|
Facility
|
IP
|
$8.00
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
3007208
|
|
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
|
|
