|
SUCTION CATHETER 6FR
|
Facility
|
IP
|
$18.00
|
|
| Hospital Charge Code |
80030298
|
|
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
|
|
|
SUCTION TIP
|
Facility
|
IP
|
$12.00
|
|
| Hospital Charge Code |
80030299
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$8.40 |
| Max. Negotiated Rate |
$12.00 |
| Rate for Payer: Aetna Commercial |
$11.40
|
| Rate for Payer: Aetna Medicare |
$10.80
|
| Rate for Payer: BCBS MT CHIP |
$10.80
|
| Rate for Payer: BCBS MT Closed Plan Network |
$11.40
|
| Rate for Payer: BCBS MT HealthLink |
$10.80
|
| Rate for Payer: BCBS MT Medicare |
$10.80
|
| Rate for Payer: BCBS MT POS |
$11.40
|
| Rate for Payer: BCBS MT Traditional |
$12.00
|
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Cigna Commercial |
$11.40
|
| Rate for Payer: Cigna Medicare |
$10.80
|
| Rate for Payer: Medicaid All Medicaid |
$11.04
|
| Rate for Payer: Medicare All Medicare |
$8.40
|
| Rate for Payer: Monida Allegiance |
$11.40
|
| Rate for Payer: Monida First Choice Health |
$11.64
|
| Rate for Payer: Monida Montana Health Co-op |
$11.40
|
| Rate for Payer: Monida PacificSource |
$11.40
|
|
|
SUCTION TIP
|
Facility
|
OP
|
$12.00
|
|
| Hospital Charge Code |
80030299
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$8.40 |
| Max. Negotiated Rate |
$12.00 |
| Rate for Payer: Aetna Commercial |
$11.40
|
| Rate for Payer: Aetna Medicare |
$10.80
|
| Rate for Payer: BCBS MT CHIP |
$10.80
|
| Rate for Payer: BCBS MT Closed Plan Network |
$11.40
|
| Rate for Payer: BCBS MT HealthLink |
$10.80
|
| Rate for Payer: BCBS MT Medicare |
$10.80
|
| Rate for Payer: BCBS MT POS |
$11.40
|
| Rate for Payer: BCBS MT Traditional |
$12.00
|
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Cigna Commercial |
$11.40
|
| Rate for Payer: Cigna Medicare |
$10.80
|
| Rate for Payer: Medicaid All Medicaid |
$11.04
|
| Rate for Payer: Medicare All Medicare |
$8.40
|
| Rate for Payer: Monida Allegiance |
$11.40
|
| Rate for Payer: Monida First Choice Health |
$11.64
|
| Rate for Payer: Monida Montana Health Co-op |
$11.40
|
| Rate for Payer: Monida PacificSource |
$11.40
|
|
|
SUCTION TUBING 6FT
|
Facility
|
IP
|
$27.00
|
|
| Hospital Charge Code |
80030297
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$18.90 |
| Max. Negotiated Rate |
$27.00 |
| Rate for Payer: Aetna Commercial |
$25.65
|
| Rate for Payer: Aetna Medicare |
$24.30
|
| Rate for Payer: BCBS MT CHIP |
$24.30
|
| Rate for Payer: BCBS MT Closed Plan Network |
$25.65
|
| Rate for Payer: BCBS MT HealthLink |
$24.30
|
| Rate for Payer: BCBS MT Medicare |
$24.30
|
| Rate for Payer: BCBS MT POS |
$25.65
|
| Rate for Payer: BCBS MT Traditional |
$27.00
|
| Rate for Payer: Cash Price |
$24.30
|
| Rate for Payer: Cigna Commercial |
$25.65
|
| Rate for Payer: Cigna Medicare |
$24.30
|
| Rate for Payer: Medicaid All Medicaid |
$24.84
|
| Rate for Payer: Medicare All Medicare |
$18.90
|
| Rate for Payer: Monida Allegiance |
$25.65
|
| Rate for Payer: Monida First Choice Health |
$26.19
|
| Rate for Payer: Monida Montana Health Co-op |
$25.65
|
| Rate for Payer: Monida PacificSource |
$25.65
|
|
|
SUCTION TUBING 6FT
|
Facility
|
OP
|
$27.00
|
|
| Hospital Charge Code |
80030297
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$18.90 |
| Max. Negotiated Rate |
$27.00 |
| Rate for Payer: Aetna Commercial |
$25.65
|
| Rate for Payer: Aetna Medicare |
$24.30
|
| Rate for Payer: BCBS MT CHIP |
$24.30
|
| Rate for Payer: BCBS MT Closed Plan Network |
$25.65
|
| Rate for Payer: BCBS MT HealthLink |
$24.30
|
| Rate for Payer: BCBS MT Medicare |
$24.30
|
| Rate for Payer: BCBS MT POS |
$25.65
|
| Rate for Payer: BCBS MT Traditional |
$27.00
|
| Rate for Payer: Cash Price |
$24.30
|
| Rate for Payer: Cigna Commercial |
$25.65
|
| Rate for Payer: Cigna Medicare |
$24.30
|
| Rate for Payer: Medicaid All Medicaid |
$24.84
|
| Rate for Payer: Medicare All Medicare |
$18.90
|
| Rate for Payer: Monida Allegiance |
$25.65
|
| Rate for Payer: Monida First Choice Health |
$26.19
|
| Rate for Payer: Monida Montana Health Co-op |
$25.65
|
| Rate for Payer: Monida PacificSource |
$25.65
|
|
|
SUGAMMADEX INJ [200MG/2ML]
|
Facility
|
IP
|
$452.00
|
|
|
Service Code
|
NDC 00006542312
|
| Hospital Charge Code |
3000529
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$316.40 |
| Max. Negotiated Rate |
$452.00 |
| Rate for Payer: Aetna Commercial |
$429.40
|
| Rate for Payer: Aetna Medicare |
$406.80
|
| Rate for Payer: BCBS MT CHIP |
$406.80
|
| Rate for Payer: BCBS MT Closed Plan Network |
$429.40
|
| Rate for Payer: BCBS MT HealthLink |
$406.80
|
| Rate for Payer: BCBS MT Medicare |
$406.80
|
| Rate for Payer: BCBS MT POS |
$429.40
|
| Rate for Payer: BCBS MT Traditional |
$452.00
|
| Rate for Payer: Cash Price |
$406.80
|
| Rate for Payer: Cigna Commercial |
$429.40
|
| Rate for Payer: Cigna Medicare |
$406.80
|
| Rate for Payer: Medicaid All Medicaid |
$415.84
|
| Rate for Payer: Medicare All Medicare |
$316.40
|
| Rate for Payer: Monida Allegiance |
$429.40
|
| Rate for Payer: Monida First Choice Health |
$438.44
|
| Rate for Payer: Monida Montana Health Co-op |
$429.40
|
| Rate for Payer: Monida PacificSource |
$429.40
|
|
|
SUGAMMADEX INJ [200MG/2ML]
|
Facility
|
OP
|
$452.00
|
|
|
Service Code
|
NDC 00006542312
|
| Hospital Charge Code |
3000529
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$316.40 |
| Max. Negotiated Rate |
$452.00 |
| Rate for Payer: Aetna Commercial |
$429.40
|
| Rate for Payer: Aetna Medicare |
$406.80
|
| Rate for Payer: BCBS MT CHIP |
$406.80
|
| Rate for Payer: BCBS MT Closed Plan Network |
$429.40
|
| Rate for Payer: BCBS MT HealthLink |
$406.80
|
| Rate for Payer: BCBS MT Medicare |
$406.80
|
| Rate for Payer: BCBS MT POS |
$429.40
|
| Rate for Payer: BCBS MT Traditional |
$452.00
|
| Rate for Payer: Cash Price |
$406.80
|
| Rate for Payer: Cigna Commercial |
$429.40
|
| Rate for Payer: Cigna Medicare |
$406.80
|
| Rate for Payer: Medicaid All Medicaid |
$415.84
|
| Rate for Payer: Medicare All Medicare |
$316.40
|
| Rate for Payer: Monida Allegiance |
$429.40
|
| Rate for Payer: Monida First Choice Health |
$438.44
|
| Rate for Payer: Monida Montana Health Co-op |
$429.40
|
| Rate for Payer: Monida PacificSource |
$429.40
|
|
|
SULFAMETH/ TMP DS TAB [800-160 MG]
|
Facility
|
IP
|
$8.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
3000437
|
|
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
|
|
|
SULFAMETH/ TMP DS TAB [800-160 MG]
|
Facility
|
OP
|
$8.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
3000437
|
|
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
|
|
|
SULFASASALAZINE TAB [500 MG]
|
Facility
|
OP
|
$8.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
3000438
|
|
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
|
|
|
SULFASASALAZINE TAB [500 MG]
|
Facility
|
IP
|
$8.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
3000438
|
|
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
|
|
|
SUMATRIPTAN INJ [6 MG/0.5 ML]
|
Facility
|
IP
|
$286.00
|
|
|
Service Code
|
HCPCS J3030
|
| Hospital Charge Code |
3000439
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$200.20 |
| Max. Negotiated Rate |
$286.00 |
| Rate for Payer: Aetna Commercial |
$271.70
|
| Rate for Payer: Aetna Medicare |
$257.40
|
| Rate for Payer: BCBS MT CHIP |
$257.40
|
| Rate for Payer: BCBS MT Closed Plan Network |
$271.70
|
| Rate for Payer: BCBS MT HealthLink |
$257.40
|
| Rate for Payer: BCBS MT Medicare |
$257.40
|
| Rate for Payer: BCBS MT POS |
$271.70
|
| Rate for Payer: BCBS MT Traditional |
$286.00
|
| Rate for Payer: Cash Price |
$257.40
|
| Rate for Payer: Cigna Commercial |
$271.70
|
| Rate for Payer: Cigna Medicare |
$257.40
|
| Rate for Payer: Medicaid All Medicaid |
$263.12
|
| Rate for Payer: Medicare All Medicare |
$200.20
|
| Rate for Payer: Monida Allegiance |
$271.70
|
| Rate for Payer: Monida First Choice Health |
$277.42
|
| Rate for Payer: Monida Montana Health Co-op |
$271.70
|
| Rate for Payer: Monida PacificSource |
$271.70
|
|
|
SUMATRIPTAN INJ [6 MG/0.5 ML]
|
Facility
|
OP
|
$286.00
|
|
|
Service Code
|
HCPCS J3030
|
| Hospital Charge Code |
3000439
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$200.20 |
| Max. Negotiated Rate |
$286.00 |
| Rate for Payer: Aetna Commercial |
$271.70
|
| Rate for Payer: Aetna Medicare |
$257.40
|
| Rate for Payer: BCBS MT CHIP |
$257.40
|
| Rate for Payer: BCBS MT Closed Plan Network |
$271.70
|
| Rate for Payer: BCBS MT HealthLink |
$257.40
|
| Rate for Payer: BCBS MT Medicare |
$257.40
|
| Rate for Payer: BCBS MT POS |
$271.70
|
| Rate for Payer: BCBS MT Traditional |
$286.00
|
| Rate for Payer: Cash Price |
$257.40
|
| Rate for Payer: Cigna Commercial |
$271.70
|
| Rate for Payer: Cigna Medicare |
$257.40
|
| Rate for Payer: Medicaid All Medicaid |
$263.12
|
| Rate for Payer: Medicare All Medicare |
$200.20
|
| Rate for Payer: Monida Allegiance |
$271.70
|
| Rate for Payer: Monida First Choice Health |
$277.42
|
| Rate for Payer: Monida Montana Health Co-op |
$271.70
|
| Rate for Payer: Monida PacificSource |
$271.70
|
|
|
SUPPLIES
|
Facility
|
OP
|
$8.00
|
|
|
Service Code
|
HCPCS 99070
|
| Hospital Charge Code |
8099070
|
|
Hospital Revenue Code
|
290
|
| 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
|
|
|
SUPPLIES
|
Facility
|
IP
|
$8.00
|
|
|
Service Code
|
HCPCS 99070
|
| Hospital Charge Code |
8099070
|
|
Hospital Revenue Code
|
290
|
| 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
|
|
|
SUPPLIES AIRCAST ANKLE
|
Facility
|
IP
|
$176.00
|
|
|
Service Code
|
HCPCS L4350
|
| Hospital Charge Code |
8004350
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$123.20 |
| Max. Negotiated Rate |
$176.00 |
| Rate for Payer: Aetna Commercial |
$167.20
|
| Rate for Payer: Aetna Medicare |
$158.40
|
| Rate for Payer: BCBS MT CHIP |
$158.40
|
| Rate for Payer: BCBS MT Closed Plan Network |
$167.20
|
| Rate for Payer: BCBS MT HealthLink |
$158.40
|
| Rate for Payer: BCBS MT Medicare |
$158.40
|
| Rate for Payer: BCBS MT POS |
$167.20
|
| Rate for Payer: BCBS MT Traditional |
$176.00
|
| Rate for Payer: Cash Price |
$158.40
|
| Rate for Payer: Cigna Commercial |
$167.20
|
| Rate for Payer: Cigna Medicare |
$158.40
|
| Rate for Payer: Medicaid All Medicaid |
$161.92
|
| Rate for Payer: Medicare All Medicare |
$123.20
|
| Rate for Payer: Monida Allegiance |
$167.20
|
| Rate for Payer: Monida First Choice Health |
$170.72
|
| Rate for Payer: Monida Montana Health Co-op |
$167.20
|
| Rate for Payer: Monida PacificSource |
$167.20
|
|
|
SUPPLIES AIRCAST ANKLE
|
Facility
|
OP
|
$176.00
|
|
|
Service Code
|
HCPCS L4350
|
| Hospital Charge Code |
8004350
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$123.20 |
| Max. Negotiated Rate |
$176.00 |
| Rate for Payer: Aetna Commercial |
$167.20
|
| Rate for Payer: Aetna Medicare |
$158.40
|
| Rate for Payer: BCBS MT CHIP |
$158.40
|
| Rate for Payer: BCBS MT Closed Plan Network |
$167.20
|
| Rate for Payer: BCBS MT HealthLink |
$158.40
|
| Rate for Payer: BCBS MT Medicare |
$158.40
|
| Rate for Payer: BCBS MT POS |
$167.20
|
| Rate for Payer: BCBS MT Traditional |
$176.00
|
| Rate for Payer: Cash Price |
$158.40
|
| Rate for Payer: Cigna Commercial |
$167.20
|
| Rate for Payer: Cigna Medicare |
$158.40
|
| Rate for Payer: Medicaid All Medicaid |
$161.92
|
| Rate for Payer: Medicare All Medicare |
$123.20
|
| Rate for Payer: Monida Allegiance |
$167.20
|
| Rate for Payer: Monida First Choice Health |
$170.72
|
| Rate for Payer: Monida Montana Health Co-op |
$167.20
|
| Rate for Payer: Monida PacificSource |
$167.20
|
|
|
SUPPLIES-CERVICAL FOAM COLLAR
|
Facility
|
IP
|
$53.00
|
|
|
Service Code
|
HCPCS L0120
|
| Hospital Charge Code |
8000120
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$37.10 |
| Max. Negotiated Rate |
$53.00 |
| Rate for Payer: Aetna Commercial |
$50.35
|
| Rate for Payer: Aetna Medicare |
$47.70
|
| Rate for Payer: BCBS MT CHIP |
$47.70
|
| Rate for Payer: BCBS MT Closed Plan Network |
$50.35
|
| Rate for Payer: BCBS MT HealthLink |
$47.70
|
| Rate for Payer: BCBS MT Medicare |
$47.70
|
| Rate for Payer: BCBS MT POS |
$50.35
|
| Rate for Payer: BCBS MT Traditional |
$53.00
|
| Rate for Payer: Cash Price |
$47.70
|
| Rate for Payer: Cigna Commercial |
$50.35
|
| Rate for Payer: Cigna Medicare |
$47.70
|
| Rate for Payer: Medicaid All Medicaid |
$48.76
|
| Rate for Payer: Medicare All Medicare |
$37.10
|
| Rate for Payer: Monida Allegiance |
$50.35
|
| Rate for Payer: Monida First Choice Health |
$51.41
|
| Rate for Payer: Monida Montana Health Co-op |
$50.35
|
| Rate for Payer: Monida PacificSource |
$50.35
|
|
|
SUPPLIES-CERVICAL FOAM COLLAR
|
Facility
|
OP
|
$53.00
|
|
|
Service Code
|
HCPCS L0120
|
| Hospital Charge Code |
8000120
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$37.10 |
| Max. Negotiated Rate |
$53.00 |
| Rate for Payer: Aetna Commercial |
$50.35
|
| Rate for Payer: Aetna Medicare |
$47.70
|
| Rate for Payer: BCBS MT CHIP |
$47.70
|
| Rate for Payer: BCBS MT Closed Plan Network |
$50.35
|
| Rate for Payer: BCBS MT HealthLink |
$47.70
|
| Rate for Payer: BCBS MT Medicare |
$47.70
|
| Rate for Payer: BCBS MT POS |
$50.35
|
| Rate for Payer: BCBS MT Traditional |
$53.00
|
| Rate for Payer: Cash Price |
$47.70
|
| Rate for Payer: Cigna Commercial |
$50.35
|
| Rate for Payer: Cigna Medicare |
$47.70
|
| Rate for Payer: Medicaid All Medicaid |
$48.76
|
| Rate for Payer: Medicare All Medicare |
$37.10
|
| Rate for Payer: Monida Allegiance |
$50.35
|
| Rate for Payer: Monida First Choice Health |
$51.41
|
| Rate for Payer: Monida Montana Health Co-op |
$50.35
|
| Rate for Payer: Monida PacificSource |
$50.35
|
|
|
SUPPLIES CRUTCHES ALL SIZES
|
Facility
|
IP
|
$68.00
|
|
|
Service Code
|
HCPCS E0114
|
| Hospital Charge Code |
8050114
|
|
Hospital Revenue Code
|
290
|
| 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
|
|
|
SUPPLIES CRUTCHES ALL SIZES
|
Facility
|
OP
|
$68.00
|
|
|
Service Code
|
HCPCS E0114
|
| Hospital Charge Code |
8050114
|
|
Hospital Revenue Code
|
290
|
| 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
|
|
|
SUPPLIES FRACTURE BOOT SM-MED-LG
|
Facility
|
OP
|
$328.00
|
|
|
Service Code
|
HCPCS L4386
|
| Hospital Charge Code |
8004386
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$229.60 |
| Max. Negotiated Rate |
$328.00 |
| Rate for Payer: Aetna Commercial |
$311.60
|
| Rate for Payer: Aetna Medicare |
$295.20
|
| Rate for Payer: BCBS MT CHIP |
$295.20
|
| Rate for Payer: BCBS MT Closed Plan Network |
$311.60
|
| Rate for Payer: BCBS MT HealthLink |
$295.20
|
| Rate for Payer: BCBS MT Medicare |
$295.20
|
| Rate for Payer: BCBS MT POS |
$311.60
|
| Rate for Payer: BCBS MT Traditional |
$328.00
|
| Rate for Payer: Cash Price |
$295.20
|
| Rate for Payer: Cigna Commercial |
$311.60
|
| Rate for Payer: Cigna Medicare |
$295.20
|
| Rate for Payer: Medicaid All Medicaid |
$301.76
|
| Rate for Payer: Medicare All Medicare |
$229.60
|
| Rate for Payer: Monida Allegiance |
$311.60
|
| Rate for Payer: Monida First Choice Health |
$318.16
|
| Rate for Payer: Monida Montana Health Co-op |
$311.60
|
| Rate for Payer: Monida PacificSource |
$311.60
|
|
|
SUPPLIES FRACTURE BOOT SM-MED-LG
|
Facility
|
IP
|
$328.00
|
|
|
Service Code
|
HCPCS L4386
|
| Hospital Charge Code |
8004386
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$229.60 |
| Max. Negotiated Rate |
$328.00 |
| Rate for Payer: Aetna Commercial |
$311.60
|
| Rate for Payer: Aetna Medicare |
$295.20
|
| Rate for Payer: BCBS MT CHIP |
$295.20
|
| Rate for Payer: BCBS MT Closed Plan Network |
$311.60
|
| Rate for Payer: BCBS MT HealthLink |
$295.20
|
| Rate for Payer: BCBS MT Medicare |
$295.20
|
| Rate for Payer: BCBS MT POS |
$311.60
|
| Rate for Payer: BCBS MT Traditional |
$328.00
|
| Rate for Payer: Cash Price |
$295.20
|
| Rate for Payer: Cigna Commercial |
$311.60
|
| Rate for Payer: Cigna Medicare |
$295.20
|
| Rate for Payer: Medicaid All Medicaid |
$301.76
|
| Rate for Payer: Medicare All Medicare |
$229.60
|
| Rate for Payer: Monida Allegiance |
$311.60
|
| Rate for Payer: Monida First Choice Health |
$318.16
|
| Rate for Payer: Monida Montana Health Co-op |
$311.60
|
| Rate for Payer: Monida PacificSource |
$311.60
|
|
|
SUPPLIES HANDIVENT NEBULIZER
|
Facility
|
IP
|
$17.00
|
|
|
Service Code
|
HCPCS A7003
|
| Hospital Charge Code |
8007333
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$11.90 |
| Max. Negotiated Rate |
$17.00 |
| Rate for Payer: Aetna Commercial |
$16.15
|
| Rate for Payer: Aetna Medicare |
$15.30
|
| Rate for Payer: BCBS MT CHIP |
$15.30
|
| Rate for Payer: BCBS MT Closed Plan Network |
$16.15
|
| Rate for Payer: BCBS MT HealthLink |
$15.30
|
| Rate for Payer: BCBS MT Medicare |
$15.30
|
| Rate for Payer: BCBS MT POS |
$16.15
|
| Rate for Payer: BCBS MT Traditional |
$17.00
|
| Rate for Payer: Cash Price |
$15.30
|
| Rate for Payer: Cigna Commercial |
$16.15
|
| Rate for Payer: Cigna Medicare |
$15.30
|
| Rate for Payer: Medicaid All Medicaid |
$15.64
|
| Rate for Payer: Medicare All Medicare |
$11.90
|
| Rate for Payer: Monida Allegiance |
$16.15
|
| Rate for Payer: Monida First Choice Health |
$16.49
|
| Rate for Payer: Monida Montana Health Co-op |
$16.15
|
| Rate for Payer: Monida PacificSource |
$16.15
|
|
|
SUPPLIES HANDIVENT NEBULIZER
|
Facility
|
OP
|
$17.00
|
|
|
Service Code
|
HCPCS A7003
|
| Hospital Charge Code |
8007333
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$11.90 |
| Max. Negotiated Rate |
$17.00 |
| Rate for Payer: Aetna Commercial |
$16.15
|
| Rate for Payer: Aetna Medicare |
$15.30
|
| Rate for Payer: BCBS MT CHIP |
$15.30
|
| Rate for Payer: BCBS MT Closed Plan Network |
$16.15
|
| Rate for Payer: BCBS MT HealthLink |
$15.30
|
| Rate for Payer: BCBS MT Medicare |
$15.30
|
| Rate for Payer: BCBS MT POS |
$16.15
|
| Rate for Payer: BCBS MT Traditional |
$17.00
|
| Rate for Payer: Cash Price |
$15.30
|
| Rate for Payer: Cigna Commercial |
$16.15
|
| Rate for Payer: Cigna Medicare |
$15.30
|
| Rate for Payer: Medicaid All Medicaid |
$15.64
|
| Rate for Payer: Medicare All Medicare |
$11.90
|
| Rate for Payer: Monida Allegiance |
$16.15
|
| Rate for Payer: Monida First Choice Health |
$16.49
|
| Rate for Payer: Monida Montana Health Co-op |
$16.15
|
| Rate for Payer: Monida PacificSource |
$16.15
|
|
