|
ARMOUR THYROID TAB [60 MG] NF
|
Facility
|
IP
|
$8.00
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
3007204
|
|
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
|
|
|
ARM SLING LG
|
Facility
|
IP
|
$15.00
|
|
| Hospital Charge Code |
2893186
|
|
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 LG
|
Facility
|
OP
|
$15.00
|
|
| Hospital Charge Code |
2893186
|
|
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 MED
|
Facility
|
IP
|
$15.00
|
|
| Hospital Charge Code |
2893185
|
|
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 MED
|
Facility
|
OP
|
$15.00
|
|
| Hospital Charge Code |
2893185
|
|
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
|
IP
|
$16.00
|
|
| Hospital Charge Code |
2893183
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$11.20 |
| Max. Negotiated Rate |
$16.00 |
| Rate for Payer: Aetna Commercial |
$15.20
|
| Rate for Payer: Aetna Medicare |
$14.40
|
| Rate for Payer: BCBS MT CHIP |
$14.40
|
| Rate for Payer: BCBS MT Closed Plan Network |
$15.20
|
| Rate for Payer: BCBS MT HealthLink |
$14.40
|
| Rate for Payer: BCBS MT Medicare |
$14.40
|
| Rate for Payer: BCBS MT POS |
$15.20
|
| Rate for Payer: BCBS MT Traditional |
$16.00
|
| Rate for Payer: Cash Price |
$14.40
|
| Rate for Payer: Cigna Commercial |
$15.20
|
| Rate for Payer: Cigna Medicare |
$14.40
|
| Rate for Payer: Medicaid All Medicaid |
$14.72
|
| Rate for Payer: Medicare All Medicare |
$11.20
|
| Rate for Payer: Monida Allegiance |
$15.20
|
| Rate for Payer: Monida First Choice Health |
$15.52
|
| Rate for Payer: Monida Montana Health Co-op |
$15.20
|
| Rate for Payer: Monida PacificSource |
$15.20
|
|
|
ARM SLING PEDS
|
Facility
|
OP
|
$16.00
|
|
| Hospital Charge Code |
2893183
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$11.20 |
| Max. Negotiated Rate |
$16.00 |
| Rate for Payer: Aetna Commercial |
$15.20
|
| Rate for Payer: Aetna Medicare |
$14.40
|
| Rate for Payer: BCBS MT CHIP |
$14.40
|
| Rate for Payer: BCBS MT Closed Plan Network |
$15.20
|
| Rate for Payer: BCBS MT HealthLink |
$14.40
|
| Rate for Payer: BCBS MT Medicare |
$14.40
|
| Rate for Payer: BCBS MT POS |
$15.20
|
| Rate for Payer: BCBS MT Traditional |
$16.00
|
| Rate for Payer: Cash Price |
$14.40
|
| Rate for Payer: Cigna Commercial |
$15.20
|
| Rate for Payer: Cigna Medicare |
$14.40
|
| Rate for Payer: Medicaid All Medicaid |
$14.72
|
| Rate for Payer: Medicare All Medicare |
$11.20
|
| Rate for Payer: Monida Allegiance |
$15.20
|
| Rate for Payer: Monida First Choice Health |
$15.52
|
| Rate for Payer: Monida Montana Health Co-op |
$15.20
|
| Rate for Payer: Monida PacificSource |
$15.20
|
|
|
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
|
$15.00
|
|
| Hospital Charge Code |
2893184
|
|
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 SM
|
Facility
|
IP
|
$15.00
|
|
| Hospital Charge Code |
2893184
|
|
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 XL
|
Facility
|
IP
|
$15.00
|
|
| Hospital Charge Code |
2893187
|
|
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 XL
|
Facility
|
OP
|
$15.00
|
|
| Hospital Charge Code |
2893187
|
|
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
|
|
|
.ARTERIAL PUNCTURE
|
Facility
|
IP
|
$188.00
|
|
|
Service Code
|
CPT 36600
|
| Hospital Charge Code |
4000078
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$131.60 |
| Max. Negotiated Rate |
$188.00 |
| Rate for Payer: Aetna Commercial |
$178.60
|
| Rate for Payer: Aetna Medicare |
$169.20
|
| Rate for Payer: BCBS MT CHIP |
$169.20
|
| Rate for Payer: BCBS MT Closed Plan Network |
$178.60
|
| Rate for Payer: BCBS MT HealthLink |
$169.20
|
| Rate for Payer: BCBS MT Medicare |
$169.20
|
| Rate for Payer: BCBS MT POS |
$178.60
|
| Rate for Payer: BCBS MT Traditional |
$188.00
|
| Rate for Payer: Cash Price |
$169.20
|
| Rate for Payer: Cigna Commercial |
$178.60
|
| Rate for Payer: Cigna Medicare |
$169.20
|
| Rate for Payer: Medicaid All Medicaid |
$172.96
|
| Rate for Payer: Medicare All Medicare |
$131.60
|
| Rate for Payer: Monida Allegiance |
$178.60
|
| Rate for Payer: Monida First Choice Health |
$182.36
|
| Rate for Payer: Monida Montana Health Co-op |
$178.60
|
| Rate for Payer: Monida PacificSource |
$178.60
|
|
|
.ARTERIAL PUNCTURE
|
Facility
|
OP
|
$188.00
|
|
|
Service Code
|
CPT 36600
|
| Hospital Charge Code |
4000078
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$131.60 |
| Max. Negotiated Rate |
$188.00 |
| Rate for Payer: Aetna Commercial |
$178.60
|
| Rate for Payer: Aetna Medicare |
$169.20
|
| Rate for Payer: BCBS MT CHIP |
$169.20
|
| Rate for Payer: BCBS MT Closed Plan Network |
$178.60
|
| Rate for Payer: BCBS MT HealthLink |
$169.20
|
| Rate for Payer: BCBS MT Medicare |
$169.20
|
| Rate for Payer: BCBS MT POS |
$178.60
|
| Rate for Payer: BCBS MT Traditional |
$188.00
|
| Rate for Payer: Cash Price |
$169.20
|
| Rate for Payer: Cigna Commercial |
$178.60
|
| Rate for Payer: Cigna Medicare |
$169.20
|
| Rate for Payer: Medicaid All Medicaid |
$172.96
|
| Rate for Payer: Medicare All Medicare |
$131.60
|
| Rate for Payer: Monida Allegiance |
$178.60
|
| Rate for Payer: Monida First Choice Health |
$182.36
|
| Rate for Payer: Monida Montana Health Co-op |
$178.60
|
| Rate for Payer: Monida PacificSource |
$178.60
|
|
|
ASO ANTIBODIES (006031)
|
Facility
|
IP
|
$61.00
|
|
|
Service Code
|
CPT 86060
|
| Hospital Charge Code |
4086060
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$42.70 |
| Max. Negotiated Rate |
$61.00 |
| Rate for Payer: Aetna Commercial |
$57.95
|
| Rate for Payer: Aetna Medicare |
$54.90
|
| Rate for Payer: BCBS MT CHIP |
$54.90
|
| Rate for Payer: BCBS MT Closed Plan Network |
$57.95
|
| Rate for Payer: BCBS MT HealthLink |
$54.90
|
| Rate for Payer: BCBS MT Medicare |
$54.90
|
| Rate for Payer: BCBS MT POS |
$57.95
|
| Rate for Payer: BCBS MT Traditional |
$61.00
|
| Rate for Payer: Cash Price |
$54.90
|
| Rate for Payer: Cigna Commercial |
$57.95
|
| Rate for Payer: Cigna Medicare |
$54.90
|
| Rate for Payer: Medicaid All Medicaid |
$56.12
|
| Rate for Payer: Medicare All Medicare |
$42.70
|
| Rate for Payer: Monida Allegiance |
$57.95
|
| Rate for Payer: Monida First Choice Health |
$59.17
|
| Rate for Payer: Monida Montana Health Co-op |
$57.95
|
| Rate for Payer: Monida PacificSource |
$57.95
|
|
|
ASO ANTIBODIES (006031)
|
Facility
|
OP
|
$61.00
|
|
|
Service Code
|
CPT 86060
|
| Hospital Charge Code |
4086060
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$42.70 |
| Max. Negotiated Rate |
$61.00 |
| Rate for Payer: Aetna Commercial |
$57.95
|
| Rate for Payer: Aetna Medicare |
$54.90
|
| Rate for Payer: BCBS MT CHIP |
$54.90
|
| Rate for Payer: BCBS MT Closed Plan Network |
$57.95
|
| Rate for Payer: BCBS MT HealthLink |
$54.90
|
| Rate for Payer: BCBS MT Medicare |
$54.90
|
| Rate for Payer: BCBS MT POS |
$57.95
|
| Rate for Payer: BCBS MT Traditional |
$61.00
|
| Rate for Payer: Cash Price |
$54.90
|
| Rate for Payer: Cigna Commercial |
$57.95
|
| Rate for Payer: Cigna Medicare |
$54.90
|
| Rate for Payer: Medicaid All Medicaid |
$56.12
|
| Rate for Payer: Medicare All Medicare |
$42.70
|
| Rate for Payer: Monida Allegiance |
$57.95
|
| Rate for Payer: Monida First Choice Health |
$59.17
|
| Rate for Payer: Monida Montana Health Co-op |
$57.95
|
| Rate for Payer: Monida PacificSource |
$57.95
|
|
|
ASPERGILLUS ANTIGEN
|
Facility
|
OP
|
$165.00
|
|
|
Service Code
|
CPT 87305
|
| Hospital Charge Code |
4087900
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$115.50 |
| Max. Negotiated Rate |
$165.00 |
| Rate for Payer: Aetna Commercial |
$156.75
|
| Rate for Payer: Aetna Medicare |
$148.50
|
| Rate for Payer: BCBS MT CHIP |
$148.50
|
| Rate for Payer: BCBS MT Closed Plan Network |
$156.75
|
| Rate for Payer: BCBS MT HealthLink |
$148.50
|
| Rate for Payer: BCBS MT Medicare |
$148.50
|
| Rate for Payer: BCBS MT POS |
$156.75
|
| Rate for Payer: BCBS MT Traditional |
$165.00
|
| Rate for Payer: Cash Price |
$148.50
|
| Rate for Payer: Cigna Commercial |
$156.75
|
| Rate for Payer: Cigna Medicare |
$148.50
|
| Rate for Payer: Medicaid All Medicaid |
$151.80
|
| Rate for Payer: Medicare All Medicare |
$115.50
|
| Rate for Payer: Monida Allegiance |
$156.75
|
| Rate for Payer: Monida First Choice Health |
$160.05
|
| Rate for Payer: Monida Montana Health Co-op |
$156.75
|
| Rate for Payer: Monida PacificSource |
$156.75
|
|
|
ASPERGILLUS ANTIGEN
|
Facility
|
IP
|
$165.00
|
|
|
Service Code
|
CPT 87305
|
| Hospital Charge Code |
4087900
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$115.50 |
| Max. Negotiated Rate |
$165.00 |
| Rate for Payer: Aetna Commercial |
$156.75
|
| Rate for Payer: Aetna Medicare |
$148.50
|
| Rate for Payer: BCBS MT CHIP |
$148.50
|
| Rate for Payer: BCBS MT Closed Plan Network |
$156.75
|
| Rate for Payer: BCBS MT HealthLink |
$148.50
|
| Rate for Payer: BCBS MT Medicare |
$148.50
|
| Rate for Payer: BCBS MT POS |
$156.75
|
| Rate for Payer: BCBS MT Traditional |
$165.00
|
| Rate for Payer: Cash Price |
$148.50
|
| Rate for Payer: Cigna Commercial |
$156.75
|
| Rate for Payer: Cigna Medicare |
$148.50
|
| Rate for Payer: Medicaid All Medicaid |
$151.80
|
| Rate for Payer: Medicare All Medicare |
$115.50
|
| Rate for Payer: Monida Allegiance |
$156.75
|
| Rate for Payer: Monida First Choice Health |
$160.05
|
| Rate for Payer: Monida Montana Health Co-op |
$156.75
|
| Rate for Payer: Monida PacificSource |
$156.75
|
|
|
ASPERGILLUS FUMIGATUS AB IGG
|
Facility
|
IP
|
$135.00
|
|
|
Service Code
|
CPT 86606
|
| Hospital Charge Code |
4087899
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$94.50 |
| Max. Negotiated Rate |
$135.00 |
| Rate for Payer: Aetna Commercial |
$128.25
|
| Rate for Payer: Aetna Medicare |
$121.50
|
| Rate for Payer: BCBS MT CHIP |
$121.50
|
| Rate for Payer: BCBS MT Closed Plan Network |
$128.25
|
| Rate for Payer: BCBS MT HealthLink |
$121.50
|
| Rate for Payer: BCBS MT Medicare |
$121.50
|
| Rate for Payer: BCBS MT POS |
$128.25
|
| Rate for Payer: BCBS MT Traditional |
$135.00
|
| Rate for Payer: Cash Price |
$121.50
|
| Rate for Payer: Cigna Commercial |
$128.25
|
| Rate for Payer: Cigna Medicare |
$121.50
|
| Rate for Payer: Medicaid All Medicaid |
$124.20
|
| Rate for Payer: Medicare All Medicare |
$94.50
|
| Rate for Payer: Monida Allegiance |
$128.25
|
| Rate for Payer: Monida First Choice Health |
$130.95
|
| Rate for Payer: Monida Montana Health Co-op |
$128.25
|
| Rate for Payer: Monida PacificSource |
$128.25
|
|
|
ASPERGILLUS FUMIGATUS AB IGG
|
Facility
|
OP
|
$135.00
|
|
|
Service Code
|
CPT 86606
|
| Hospital Charge Code |
4087899
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$94.50 |
| Max. Negotiated Rate |
$135.00 |
| Rate for Payer: Aetna Commercial |
$128.25
|
| Rate for Payer: Aetna Medicare |
$121.50
|
| Rate for Payer: BCBS MT CHIP |
$121.50
|
| Rate for Payer: BCBS MT Closed Plan Network |
$128.25
|
| Rate for Payer: BCBS MT HealthLink |
$121.50
|
| Rate for Payer: BCBS MT Medicare |
$121.50
|
| Rate for Payer: BCBS MT POS |
$128.25
|
| Rate for Payer: BCBS MT Traditional |
$135.00
|
| Rate for Payer: Cash Price |
$121.50
|
| Rate for Payer: Cigna Commercial |
$128.25
|
| Rate for Payer: Cigna Medicare |
$121.50
|
| Rate for Payer: Medicaid All Medicaid |
$124.20
|
| Rate for Payer: Medicare All Medicare |
$94.50
|
| Rate for Payer: Monida Allegiance |
$128.25
|
| Rate for Payer: Monida First Choice Health |
$130.95
|
| Rate for Payer: Monida Montana Health Co-op |
$128.25
|
| Rate for Payer: Monida PacificSource |
$128.25
|
|
|
ASPERGILLUS FUMIGATUS IGE
|
Facility
|
IP
|
$68.00
|
|
|
Service Code
|
CPT 86003
|
| Hospital Charge Code |
4088028
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$47.60 |
| Max. Negotiated Rate |
$68.00 |
| Rate for Payer: Aetna Commercial |
$64.60
|
| Rate for Payer: Aetna Medicare |
$61.20
|
| Rate for Payer: BCBS MT CHIP |
$61.20
|
| Rate for Payer: BCBS MT Closed Plan Network |
$64.60
|
| Rate for Payer: BCBS MT HealthLink |
$61.20
|
| Rate for Payer: BCBS MT Medicare |
$61.20
|
| Rate for Payer: BCBS MT POS |
$64.60
|
| Rate for Payer: BCBS MT Traditional |
$68.00
|
| Rate for Payer: Cash Price |
$61.20
|
| Rate for Payer: Cigna Commercial |
$64.60
|
| Rate for Payer: Cigna Medicare |
$61.20
|
| Rate for Payer: Medicaid All Medicaid |
$62.56
|
| Rate for Payer: Medicare All Medicare |
$47.60
|
| Rate for Payer: Monida Allegiance |
$64.60
|
| Rate for Payer: Monida First Choice Health |
$65.96
|
| Rate for Payer: Monida Montana Health Co-op |
$64.60
|
| Rate for Payer: Monida PacificSource |
$64.60
|
|
|
ASPERGILLUS FUMIGATUS IGE
|
Facility
|
OP
|
$68.00
|
|
|
Service Code
|
CPT 86003
|
| Hospital Charge Code |
4088028
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$47.60 |
| Max. Negotiated Rate |
$68.00 |
| Rate for Payer: Aetna Commercial |
$64.60
|
| Rate for Payer: Aetna Medicare |
$61.20
|
| Rate for Payer: BCBS MT CHIP |
$61.20
|
| Rate for Payer: BCBS MT Closed Plan Network |
$64.60
|
| Rate for Payer: BCBS MT HealthLink |
$61.20
|
| Rate for Payer: BCBS MT Medicare |
$61.20
|
| Rate for Payer: BCBS MT POS |
$64.60
|
| Rate for Payer: BCBS MT Traditional |
$68.00
|
| Rate for Payer: Cash Price |
$61.20
|
| Rate for Payer: Cigna Commercial |
$64.60
|
| Rate for Payer: Cigna Medicare |
$61.20
|
| Rate for Payer: Medicaid All Medicaid |
$62.56
|
| Rate for Payer: Medicare All Medicare |
$47.60
|
| Rate for Payer: Monida Allegiance |
$64.60
|
| Rate for Payer: Monida First Choice Health |
$65.96
|
| Rate for Payer: Monida Montana Health Co-op |
$64.60
|
| Rate for Payer: Monida PacificSource |
$64.60
|
|
|
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 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
|
|
