|
BLOOD CULTURE
|
Facility
|
IP
|
$121.00
|
|
| Hospital Charge Code |
4070402
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$84.70 |
| Max. Negotiated Rate |
$121.00 |
| Rate for Payer: Aetna Commercial |
$114.95
|
| Rate for Payer: Aetna Medicare |
$108.90
|
| Rate for Payer: BCBS MT CHIP |
$108.90
|
| Rate for Payer: BCBS MT Closed Plan Network |
$114.95
|
| Rate for Payer: BCBS MT HealthLink |
$108.90
|
| Rate for Payer: BCBS MT Medicare |
$108.90
|
| Rate for Payer: BCBS MT POS |
$114.95
|
| Rate for Payer: BCBS MT Traditional |
$121.00
|
| Rate for Payer: Cash Price |
$108.90
|
| Rate for Payer: Cigna Commercial |
$114.95
|
| Rate for Payer: Cigna Medicare |
$108.90
|
| Rate for Payer: Medicaid All Medicaid |
$111.32
|
| Rate for Payer: Medicare All Medicare |
$84.70
|
| Rate for Payer: Monida Allegiance |
$114.95
|
| Rate for Payer: Monida First Choice Health |
$117.37
|
| Rate for Payer: Monida Montana Health Co-op |
$114.95
|
| Rate for Payer: Monida PacificSource |
$114.95
|
|
|
BLOOD CULTURE, PEDIATRIC (008300)
|
Facility
|
IP
|
$65.00
|
|
|
Service Code
|
HCPCS 87040
|
| Hospital Charge Code |
4070403
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$45.50 |
| Max. Negotiated Rate |
$65.00 |
| Rate for Payer: Aetna Commercial |
$61.75
|
| Rate for Payer: Aetna Medicare |
$58.50
|
| Rate for Payer: BCBS MT CHIP |
$58.50
|
| Rate for Payer: BCBS MT Closed Plan Network |
$61.75
|
| Rate for Payer: BCBS MT HealthLink |
$58.50
|
| Rate for Payer: BCBS MT Medicare |
$58.50
|
| Rate for Payer: BCBS MT POS |
$61.75
|
| Rate for Payer: BCBS MT Traditional |
$65.00
|
| Rate for Payer: Cash Price |
$58.50
|
| Rate for Payer: Cigna Commercial |
$61.75
|
| Rate for Payer: Cigna Medicare |
$58.50
|
| Rate for Payer: Medicaid All Medicaid |
$59.80
|
| Rate for Payer: Medicare All Medicare |
$45.50
|
| Rate for Payer: Monida Allegiance |
$61.75
|
| Rate for Payer: Monida First Choice Health |
$63.05
|
| Rate for Payer: Monida Montana Health Co-op |
$61.75
|
| Rate for Payer: Monida PacificSource |
$61.75
|
|
|
BLOOD CULTURE, PEDIATRIC (008300)
|
Facility
|
OP
|
$65.00
|
|
|
Service Code
|
HCPCS 87040
|
| Hospital Charge Code |
4070403
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$45.50 |
| Max. Negotiated Rate |
$65.00 |
| Rate for Payer: Aetna Commercial |
$61.75
|
| Rate for Payer: Aetna Medicare |
$58.50
|
| Rate for Payer: BCBS MT CHIP |
$58.50
|
| Rate for Payer: BCBS MT Closed Plan Network |
$61.75
|
| Rate for Payer: BCBS MT HealthLink |
$58.50
|
| Rate for Payer: BCBS MT Medicare |
$58.50
|
| Rate for Payer: BCBS MT POS |
$61.75
|
| Rate for Payer: BCBS MT Traditional |
$65.00
|
| Rate for Payer: Cash Price |
$58.50
|
| Rate for Payer: Cigna Commercial |
$61.75
|
| Rate for Payer: Cigna Medicare |
$58.50
|
| Rate for Payer: Medicaid All Medicaid |
$59.80
|
| Rate for Payer: Medicare All Medicare |
$45.50
|
| Rate for Payer: Monida Allegiance |
$61.75
|
| Rate for Payer: Monida First Choice Health |
$63.05
|
| Rate for Payer: Monida Montana Health Co-op |
$61.75
|
| Rate for Payer: Monida PacificSource |
$61.75
|
|
|
BLOOD CULTURE, SET 1 (008300)
|
Facility
|
OP
|
$65.00
|
|
|
Service Code
|
HCPCS 87040
|
| Hospital Charge Code |
4087040
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$45.50 |
| Max. Negotiated Rate |
$65.00 |
| Rate for Payer: Aetna Commercial |
$61.75
|
| Rate for Payer: Aetna Medicare |
$58.50
|
| Rate for Payer: BCBS MT CHIP |
$58.50
|
| Rate for Payer: BCBS MT Closed Plan Network |
$61.75
|
| Rate for Payer: BCBS MT HealthLink |
$58.50
|
| Rate for Payer: BCBS MT Medicare |
$58.50
|
| Rate for Payer: BCBS MT POS |
$61.75
|
| Rate for Payer: BCBS MT Traditional |
$65.00
|
| Rate for Payer: Cash Price |
$58.50
|
| Rate for Payer: Cigna Commercial |
$61.75
|
| Rate for Payer: Cigna Medicare |
$58.50
|
| Rate for Payer: Medicaid All Medicaid |
$59.80
|
| Rate for Payer: Medicare All Medicare |
$45.50
|
| Rate for Payer: Monida Allegiance |
$61.75
|
| Rate for Payer: Monida First Choice Health |
$63.05
|
| Rate for Payer: Monida Montana Health Co-op |
$61.75
|
| Rate for Payer: Monida PacificSource |
$61.75
|
|
|
BLOOD CULTURE, SET 1 (008300)
|
Facility
|
IP
|
$65.00
|
|
|
Service Code
|
HCPCS 87040
|
| Hospital Charge Code |
4087040
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$45.50 |
| Max. Negotiated Rate |
$65.00 |
| Rate for Payer: Aetna Commercial |
$61.75
|
| Rate for Payer: Aetna Medicare |
$58.50
|
| Rate for Payer: BCBS MT CHIP |
$58.50
|
| Rate for Payer: BCBS MT Closed Plan Network |
$61.75
|
| Rate for Payer: BCBS MT HealthLink |
$58.50
|
| Rate for Payer: BCBS MT Medicare |
$58.50
|
| Rate for Payer: BCBS MT POS |
$61.75
|
| Rate for Payer: BCBS MT Traditional |
$65.00
|
| Rate for Payer: Cash Price |
$58.50
|
| Rate for Payer: Cigna Commercial |
$61.75
|
| Rate for Payer: Cigna Medicare |
$58.50
|
| Rate for Payer: Medicaid All Medicaid |
$59.80
|
| Rate for Payer: Medicare All Medicare |
$45.50
|
| Rate for Payer: Monida Allegiance |
$61.75
|
| Rate for Payer: Monida First Choice Health |
$63.05
|
| Rate for Payer: Monida Montana Health Co-op |
$61.75
|
| Rate for Payer: Monida PacificSource |
$61.75
|
|
|
BLOOD CULTURE, SET 2 (008300)
|
Facility
|
OP
|
$65.00
|
|
|
Service Code
|
HCPCS 87040 91
|
| Hospital Charge Code |
4070401
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$45.50 |
| Max. Negotiated Rate |
$65.00 |
| Rate for Payer: Aetna Commercial |
$61.75
|
| Rate for Payer: Aetna Medicare |
$58.50
|
| Rate for Payer: BCBS MT CHIP |
$58.50
|
| Rate for Payer: BCBS MT Closed Plan Network |
$61.75
|
| Rate for Payer: BCBS MT HealthLink |
$58.50
|
| Rate for Payer: BCBS MT Medicare |
$58.50
|
| Rate for Payer: BCBS MT POS |
$61.75
|
| Rate for Payer: BCBS MT Traditional |
$65.00
|
| Rate for Payer: Cash Price |
$58.50
|
| Rate for Payer: Cigna Commercial |
$61.75
|
| Rate for Payer: Cigna Medicare |
$58.50
|
| Rate for Payer: Medicaid All Medicaid |
$59.80
|
| Rate for Payer: Medicare All Medicare |
$45.50
|
| Rate for Payer: Monida Allegiance |
$61.75
|
| Rate for Payer: Monida First Choice Health |
$63.05
|
| Rate for Payer: Monida Montana Health Co-op |
$61.75
|
| Rate for Payer: Monida PacificSource |
$61.75
|
|
|
BLOOD CULTURE, SET 2 (008300)
|
Facility
|
IP
|
$65.00
|
|
|
Service Code
|
HCPCS 87040 91
|
| Hospital Charge Code |
4070401
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$45.50 |
| Max. Negotiated Rate |
$65.00 |
| Rate for Payer: Aetna Commercial |
$61.75
|
| Rate for Payer: Aetna Medicare |
$58.50
|
| Rate for Payer: BCBS MT CHIP |
$58.50
|
| Rate for Payer: BCBS MT Closed Plan Network |
$61.75
|
| Rate for Payer: BCBS MT HealthLink |
$58.50
|
| Rate for Payer: BCBS MT Medicare |
$58.50
|
| Rate for Payer: BCBS MT POS |
$61.75
|
| Rate for Payer: BCBS MT Traditional |
$65.00
|
| Rate for Payer: Cash Price |
$58.50
|
| Rate for Payer: Cigna Commercial |
$61.75
|
| Rate for Payer: Cigna Medicare |
$58.50
|
| Rate for Payer: Medicaid All Medicaid |
$59.80
|
| Rate for Payer: Medicare All Medicare |
$45.50
|
| Rate for Payer: Monida Allegiance |
$61.75
|
| Rate for Payer: Monida First Choice Health |
$63.05
|
| Rate for Payer: Monida Montana Health Co-op |
$61.75
|
| Rate for Payer: Monida PacificSource |
$61.75
|
|
|
BLOOD DRAW-IMPLANTED VENOUS DEVICE
|
Facility
|
IP
|
$134.00
|
|
|
Service Code
|
HCPCS 36591
|
| Hospital Charge Code |
1036591
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$93.80 |
| Max. Negotiated Rate |
$134.00 |
| Rate for Payer: Aetna Commercial |
$127.30
|
| Rate for Payer: Aetna Medicare |
$120.60
|
| Rate for Payer: BCBS MT CHIP |
$120.60
|
| Rate for Payer: BCBS MT Closed Plan Network |
$127.30
|
| Rate for Payer: BCBS MT HealthLink |
$120.60
|
| Rate for Payer: BCBS MT Medicare |
$120.60
|
| Rate for Payer: BCBS MT POS |
$127.30
|
| Rate for Payer: BCBS MT Traditional |
$134.00
|
| Rate for Payer: Cash Price |
$120.60
|
| Rate for Payer: Cigna Commercial |
$127.30
|
| Rate for Payer: Cigna Medicare |
$120.60
|
| Rate for Payer: Medicaid All Medicaid |
$123.28
|
| Rate for Payer: Medicare All Medicare |
$93.80
|
| Rate for Payer: Monida Allegiance |
$127.30
|
| Rate for Payer: Monida First Choice Health |
$129.98
|
| Rate for Payer: Monida Montana Health Co-op |
$127.30
|
| Rate for Payer: Monida PacificSource |
$127.30
|
|
|
BLOOD DRAW-IMPLANTED VENOUS DEVICE
|
Facility
|
OP
|
$134.00
|
|
|
Service Code
|
HCPCS 36591
|
| Hospital Charge Code |
1036591
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$93.80 |
| Max. Negotiated Rate |
$134.00 |
| Rate for Payer: Aetna Commercial |
$127.30
|
| Rate for Payer: Aetna Medicare |
$120.60
|
| Rate for Payer: BCBS MT CHIP |
$120.60
|
| Rate for Payer: BCBS MT Closed Plan Network |
$127.30
|
| Rate for Payer: BCBS MT HealthLink |
$120.60
|
| Rate for Payer: BCBS MT Medicare |
$120.60
|
| Rate for Payer: BCBS MT POS |
$127.30
|
| Rate for Payer: BCBS MT Traditional |
$134.00
|
| Rate for Payer: Cash Price |
$120.60
|
| Rate for Payer: Cigna Commercial |
$127.30
|
| Rate for Payer: Cigna Medicare |
$120.60
|
| Rate for Payer: Medicaid All Medicaid |
$123.28
|
| Rate for Payer: Medicare All Medicare |
$93.80
|
| Rate for Payer: Monida Allegiance |
$127.30
|
| Rate for Payer: Monida First Choice Health |
$129.98
|
| Rate for Payer: Monida Montana Health Co-op |
$127.30
|
| Rate for Payer: Monida PacificSource |
$127.30
|
|
|
BLOOD DRAW-PICC LINE
|
Facility
|
OP
|
$124.00
|
|
|
Service Code
|
HCPCS 36592
|
| Hospital Charge Code |
1036592
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$86.80 |
| Max. Negotiated Rate |
$124.00 |
| Rate for Payer: Aetna Commercial |
$117.80
|
| Rate for Payer: Aetna Medicare |
$111.60
|
| Rate for Payer: BCBS MT CHIP |
$111.60
|
| Rate for Payer: BCBS MT Closed Plan Network |
$117.80
|
| Rate for Payer: BCBS MT HealthLink |
$111.60
|
| Rate for Payer: BCBS MT Medicare |
$111.60
|
| Rate for Payer: BCBS MT POS |
$117.80
|
| Rate for Payer: BCBS MT Traditional |
$124.00
|
| Rate for Payer: Cash Price |
$111.60
|
| Rate for Payer: Cigna Commercial |
$117.80
|
| Rate for Payer: Cigna Medicare |
$111.60
|
| Rate for Payer: Medicaid All Medicaid |
$114.08
|
| Rate for Payer: Medicare All Medicare |
$86.80
|
| Rate for Payer: Monida Allegiance |
$117.80
|
| Rate for Payer: Monida First Choice Health |
$120.28
|
| Rate for Payer: Monida Montana Health Co-op |
$117.80
|
| Rate for Payer: Monida PacificSource |
$117.80
|
|
|
BLOOD DRAW-PICC LINE
|
Facility
|
IP
|
$124.00
|
|
|
Service Code
|
HCPCS 36592
|
| Hospital Charge Code |
1036592
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$86.80 |
| Max. Negotiated Rate |
$124.00 |
| Rate for Payer: Aetna Commercial |
$117.80
|
| Rate for Payer: Aetna Medicare |
$111.60
|
| Rate for Payer: BCBS MT CHIP |
$111.60
|
| Rate for Payer: BCBS MT Closed Plan Network |
$117.80
|
| Rate for Payer: BCBS MT HealthLink |
$111.60
|
| Rate for Payer: BCBS MT Medicare |
$111.60
|
| Rate for Payer: BCBS MT POS |
$117.80
|
| Rate for Payer: BCBS MT Traditional |
$124.00
|
| Rate for Payer: Cash Price |
$111.60
|
| Rate for Payer: Cigna Commercial |
$117.80
|
| Rate for Payer: Cigna Medicare |
$111.60
|
| Rate for Payer: Medicaid All Medicaid |
$114.08
|
| Rate for Payer: Medicare All Medicare |
$86.80
|
| Rate for Payer: Monida Allegiance |
$117.80
|
| Rate for Payer: Monida First Choice Health |
$120.28
|
| Rate for Payer: Monida Montana Health Co-op |
$117.80
|
| Rate for Payer: Monida PacificSource |
$117.80
|
|
|
BLOOD GASES, ARTERIAL
|
Facility
|
IP
|
$293.00
|
|
|
Service Code
|
HCPCS 82803
|
| Hospital Charge Code |
4082803
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$205.10 |
| Max. Negotiated Rate |
$293.00 |
| Rate for Payer: Aetna Commercial |
$278.35
|
| Rate for Payer: Aetna Medicare |
$263.70
|
| Rate for Payer: BCBS MT CHIP |
$263.70
|
| Rate for Payer: BCBS MT Closed Plan Network |
$278.35
|
| Rate for Payer: BCBS MT HealthLink |
$263.70
|
| Rate for Payer: BCBS MT Medicare |
$263.70
|
| Rate for Payer: BCBS MT POS |
$278.35
|
| Rate for Payer: BCBS MT Traditional |
$293.00
|
| Rate for Payer: Cash Price |
$263.70
|
| Rate for Payer: Cigna Commercial |
$278.35
|
| Rate for Payer: Cigna Medicare |
$263.70
|
| Rate for Payer: Medicaid All Medicaid |
$269.56
|
| Rate for Payer: Medicare All Medicare |
$205.10
|
| Rate for Payer: Monida Allegiance |
$278.35
|
| Rate for Payer: Monida First Choice Health |
$284.21
|
| Rate for Payer: Monida Montana Health Co-op |
$278.35
|
| Rate for Payer: Monida PacificSource |
$278.35
|
|
|
BLOOD GASES, ARTERIAL
|
Facility
|
OP
|
$293.00
|
|
|
Service Code
|
HCPCS 82803
|
| Hospital Charge Code |
4082803
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$205.10 |
| Max. Negotiated Rate |
$293.00 |
| Rate for Payer: Aetna Commercial |
$278.35
|
| Rate for Payer: Aetna Medicare |
$263.70
|
| Rate for Payer: BCBS MT CHIP |
$263.70
|
| Rate for Payer: BCBS MT Closed Plan Network |
$278.35
|
| Rate for Payer: BCBS MT HealthLink |
$263.70
|
| Rate for Payer: BCBS MT Medicare |
$263.70
|
| Rate for Payer: BCBS MT POS |
$278.35
|
| Rate for Payer: BCBS MT Traditional |
$293.00
|
| Rate for Payer: Cash Price |
$263.70
|
| Rate for Payer: Cigna Commercial |
$278.35
|
| Rate for Payer: Cigna Medicare |
$263.70
|
| Rate for Payer: Medicaid All Medicaid |
$269.56
|
| Rate for Payer: Medicare All Medicare |
$205.10
|
| Rate for Payer: Monida Allegiance |
$278.35
|
| Rate for Payer: Monida First Choice Health |
$284.21
|
| Rate for Payer: Monida Montana Health Co-op |
$278.35
|
| Rate for Payer: Monida PacificSource |
$278.35
|
|
|
BLOOD GASES, VENOUS
|
Facility
|
OP
|
$293.00
|
|
|
Service Code
|
HCPCS 82803
|
| Hospital Charge Code |
4000077
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$205.10 |
| Max. Negotiated Rate |
$293.00 |
| Rate for Payer: Aetna Commercial |
$278.35
|
| Rate for Payer: Aetna Medicare |
$263.70
|
| Rate for Payer: BCBS MT CHIP |
$263.70
|
| Rate for Payer: BCBS MT Closed Plan Network |
$278.35
|
| Rate for Payer: BCBS MT HealthLink |
$263.70
|
| Rate for Payer: BCBS MT Medicare |
$263.70
|
| Rate for Payer: BCBS MT POS |
$278.35
|
| Rate for Payer: BCBS MT Traditional |
$293.00
|
| Rate for Payer: Cash Price |
$263.70
|
| Rate for Payer: Cigna Commercial |
$278.35
|
| Rate for Payer: Cigna Medicare |
$263.70
|
| Rate for Payer: Medicaid All Medicaid |
$269.56
|
| Rate for Payer: Medicare All Medicare |
$205.10
|
| Rate for Payer: Monida Allegiance |
$278.35
|
| Rate for Payer: Monida First Choice Health |
$284.21
|
| Rate for Payer: Monida Montana Health Co-op |
$278.35
|
| Rate for Payer: Monida PacificSource |
$278.35
|
|
|
BLOOD GASES, VENOUS
|
Facility
|
IP
|
$293.00
|
|
|
Service Code
|
HCPCS 82803
|
| Hospital Charge Code |
4000077
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$205.10 |
| Max. Negotiated Rate |
$293.00 |
| Rate for Payer: Aetna Commercial |
$278.35
|
| Rate for Payer: Aetna Medicare |
$263.70
|
| Rate for Payer: BCBS MT CHIP |
$263.70
|
| Rate for Payer: BCBS MT Closed Plan Network |
$278.35
|
| Rate for Payer: BCBS MT HealthLink |
$263.70
|
| Rate for Payer: BCBS MT Medicare |
$263.70
|
| Rate for Payer: BCBS MT POS |
$278.35
|
| Rate for Payer: BCBS MT Traditional |
$293.00
|
| Rate for Payer: Cash Price |
$263.70
|
| Rate for Payer: Cigna Commercial |
$278.35
|
| Rate for Payer: Cigna Medicare |
$263.70
|
| Rate for Payer: Medicaid All Medicaid |
$269.56
|
| Rate for Payer: Medicare All Medicare |
$205.10
|
| Rate for Payer: Monida Allegiance |
$278.35
|
| Rate for Payer: Monida First Choice Health |
$284.21
|
| Rate for Payer: Monida Montana Health Co-op |
$278.35
|
| Rate for Payer: Monida PacificSource |
$278.35
|
|
|
BLOOD TRANSFER DEVICE (NURSING ONLY)
|
Facility
|
OP
|
$3.00
|
|
| Hospital Charge Code |
80040231
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$2.10 |
| Max. Negotiated Rate |
$3.00 |
| Rate for Payer: Aetna Commercial |
$2.85
|
| Rate for Payer: Aetna Medicare |
$2.70
|
| Rate for Payer: BCBS MT CHIP |
$2.70
|
| Rate for Payer: BCBS MT Closed Plan Network |
$2.85
|
| Rate for Payer: BCBS MT HealthLink |
$2.70
|
| Rate for Payer: BCBS MT Medicare |
$2.70
|
| Rate for Payer: BCBS MT POS |
$2.85
|
| Rate for Payer: BCBS MT Traditional |
$3.00
|
| Rate for Payer: Cash Price |
$2.70
|
| Rate for Payer: Cigna Commercial |
$2.85
|
| Rate for Payer: Cigna Medicare |
$2.70
|
| Rate for Payer: Medicaid All Medicaid |
$2.76
|
| Rate for Payer: Medicare All Medicare |
$2.10
|
| Rate for Payer: Monida Allegiance |
$2.85
|
| Rate for Payer: Monida First Choice Health |
$2.91
|
| Rate for Payer: Monida Montana Health Co-op |
$2.85
|
| Rate for Payer: Monida PacificSource |
$2.85
|
|
|
BLOOD TRANSFER DEVICE (NURSING ONLY)
|
Facility
|
IP
|
$3.00
|
|
| Hospital Charge Code |
80040231
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$2.10 |
| Max. Negotiated Rate |
$3.00 |
| Rate for Payer: Aetna Commercial |
$2.85
|
| Rate for Payer: Aetna Medicare |
$2.70
|
| Rate for Payer: BCBS MT CHIP |
$2.70
|
| Rate for Payer: BCBS MT Closed Plan Network |
$2.85
|
| Rate for Payer: BCBS MT HealthLink |
$2.70
|
| Rate for Payer: BCBS MT Medicare |
$2.70
|
| Rate for Payer: BCBS MT POS |
$2.85
|
| Rate for Payer: BCBS MT Traditional |
$3.00
|
| Rate for Payer: Cash Price |
$2.70
|
| Rate for Payer: Cigna Commercial |
$2.85
|
| Rate for Payer: Cigna Medicare |
$2.70
|
| Rate for Payer: Medicaid All Medicaid |
$2.76
|
| Rate for Payer: Medicare All Medicare |
$2.10
|
| Rate for Payer: Monida Allegiance |
$2.85
|
| Rate for Payer: Monida First Choice Health |
$2.91
|
| Rate for Payer: Monida Montana Health Co-op |
$2.85
|
| Rate for Payer: Monida PacificSource |
$2.85
|
|
|
BLOOD TRANSFER PACK BAG
|
Facility
|
OP
|
$26.00
|
|
| Hospital Charge Code |
80040141
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$18.20 |
| Max. Negotiated Rate |
$26.00 |
| Rate for Payer: Aetna Commercial |
$24.70
|
| Rate for Payer: Aetna Medicare |
$23.40
|
| Rate for Payer: BCBS MT CHIP |
$23.40
|
| Rate for Payer: BCBS MT Closed Plan Network |
$24.70
|
| Rate for Payer: BCBS MT HealthLink |
$23.40
|
| Rate for Payer: BCBS MT Medicare |
$23.40
|
| Rate for Payer: BCBS MT POS |
$24.70
|
| Rate for Payer: BCBS MT Traditional |
$26.00
|
| Rate for Payer: Cash Price |
$23.40
|
| Rate for Payer: Cigna Commercial |
$24.70
|
| Rate for Payer: Cigna Medicare |
$23.40
|
| Rate for Payer: Medicaid All Medicaid |
$23.92
|
| Rate for Payer: Medicare All Medicare |
$18.20
|
| Rate for Payer: Monida Allegiance |
$24.70
|
| Rate for Payer: Monida First Choice Health |
$25.22
|
| Rate for Payer: Monida Montana Health Co-op |
$24.70
|
| Rate for Payer: Monida PacificSource |
$24.70
|
|
|
BLOOD TRANSFER PACK BAG
|
Facility
|
IP
|
$26.00
|
|
| Hospital Charge Code |
80040141
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$18.20 |
| Max. Negotiated Rate |
$26.00 |
| Rate for Payer: Aetna Commercial |
$24.70
|
| Rate for Payer: Aetna Medicare |
$23.40
|
| Rate for Payer: BCBS MT CHIP |
$23.40
|
| Rate for Payer: BCBS MT Closed Plan Network |
$24.70
|
| Rate for Payer: BCBS MT HealthLink |
$23.40
|
| Rate for Payer: BCBS MT Medicare |
$23.40
|
| Rate for Payer: BCBS MT POS |
$24.70
|
| Rate for Payer: BCBS MT Traditional |
$26.00
|
| Rate for Payer: Cash Price |
$23.40
|
| Rate for Payer: Cigna Commercial |
$24.70
|
| Rate for Payer: Cigna Medicare |
$23.40
|
| Rate for Payer: Medicaid All Medicaid |
$23.92
|
| Rate for Payer: Medicare All Medicare |
$18.20
|
| Rate for Payer: Monida Allegiance |
$24.70
|
| Rate for Payer: Monida First Choice Health |
$25.22
|
| Rate for Payer: Monida Montana Health Co-op |
$24.70
|
| Rate for Payer: Monida PacificSource |
$24.70
|
|
|
BLOOD UREA NITROGEN (BUN)
|
Facility
|
IP
|
$58.00
|
|
|
Service Code
|
HCPCS 84520
|
| Hospital Charge Code |
4084520
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$40.60 |
| Max. Negotiated Rate |
$58.00 |
| Rate for Payer: Aetna Commercial |
$55.10
|
| Rate for Payer: Aetna Medicare |
$52.20
|
| Rate for Payer: BCBS MT CHIP |
$52.20
|
| Rate for Payer: BCBS MT Closed Plan Network |
$55.10
|
| Rate for Payer: BCBS MT HealthLink |
$52.20
|
| Rate for Payer: BCBS MT Medicare |
$52.20
|
| Rate for Payer: BCBS MT POS |
$55.10
|
| Rate for Payer: BCBS MT Traditional |
$58.00
|
| Rate for Payer: Cash Price |
$52.20
|
| Rate for Payer: Cigna Commercial |
$55.10
|
| Rate for Payer: Cigna Medicare |
$52.20
|
| Rate for Payer: Medicaid All Medicaid |
$53.36
|
| Rate for Payer: Medicare All Medicare |
$40.60
|
| Rate for Payer: Monida Allegiance |
$55.10
|
| Rate for Payer: Monida First Choice Health |
$56.26
|
| Rate for Payer: Monida Montana Health Co-op |
$55.10
|
| Rate for Payer: Monida PacificSource |
$55.10
|
|
|
BLOOD UREA NITROGEN (BUN)
|
Facility
|
OP
|
$58.00
|
|
|
Service Code
|
HCPCS 84520
|
| Hospital Charge Code |
4084520
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$40.60 |
| Max. Negotiated Rate |
$58.00 |
| Rate for Payer: Aetna Commercial |
$55.10
|
| Rate for Payer: Aetna Medicare |
$52.20
|
| Rate for Payer: BCBS MT CHIP |
$52.20
|
| Rate for Payer: BCBS MT Closed Plan Network |
$55.10
|
| Rate for Payer: BCBS MT HealthLink |
$52.20
|
| Rate for Payer: BCBS MT Medicare |
$52.20
|
| Rate for Payer: BCBS MT POS |
$55.10
|
| Rate for Payer: BCBS MT Traditional |
$58.00
|
| Rate for Payer: Cash Price |
$52.20
|
| Rate for Payer: Cigna Commercial |
$55.10
|
| Rate for Payer: Cigna Medicare |
$52.20
|
| Rate for Payer: Medicaid All Medicaid |
$53.36
|
| Rate for Payer: Medicare All Medicare |
$40.60
|
| Rate for Payer: Monida Allegiance |
$55.10
|
| Rate for Payer: Monida First Choice Health |
$56.26
|
| Rate for Payer: Monida Montana Health Co-op |
$55.10
|
| Rate for Payer: Monida PacificSource |
$55.10
|
|
|
BOTULINUM TOXIN 100UN VIAL
|
Facility
|
IP
|
$1,065.20
|
|
|
Service Code
|
HCPCS J0585
|
| Hospital Charge Code |
3007394
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$745.64 |
| Max. Negotiated Rate |
$1,065.20 |
| Rate for Payer: Aetna Commercial |
$1,011.94
|
| Rate for Payer: Aetna Medicare |
$958.68
|
| Rate for Payer: BCBS MT CHIP |
$958.68
|
| Rate for Payer: BCBS MT Closed Plan Network |
$1,011.94
|
| Rate for Payer: BCBS MT HealthLink |
$958.68
|
| Rate for Payer: BCBS MT Medicare |
$958.68
|
| Rate for Payer: BCBS MT POS |
$1,011.94
|
| Rate for Payer: BCBS MT Traditional |
$1,065.20
|
| Rate for Payer: Cash Price |
$958.68
|
| Rate for Payer: Cigna Commercial |
$1,011.94
|
| Rate for Payer: Cigna Medicare |
$958.68
|
| Rate for Payer: Medicaid All Medicaid |
$979.98
|
| Rate for Payer: Medicare All Medicare |
$745.64
|
| Rate for Payer: Monida Allegiance |
$1,011.94
|
| Rate for Payer: Monida First Choice Health |
$1,033.24
|
| Rate for Payer: Monida Montana Health Co-op |
$1,011.94
|
| Rate for Payer: Monida PacificSource |
$1,011.94
|
|
|
BOTULINUM TOXIN 100UN VIAL
|
Facility
|
OP
|
$1,065.20
|
|
|
Service Code
|
HCPCS J0585
|
| Hospital Charge Code |
3007394
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$745.64 |
| Max. Negotiated Rate |
$1,065.20 |
| Rate for Payer: Aetna Commercial |
$1,011.94
|
| Rate for Payer: Aetna Medicare |
$958.68
|
| Rate for Payer: BCBS MT CHIP |
$958.68
|
| Rate for Payer: BCBS MT Closed Plan Network |
$1,011.94
|
| Rate for Payer: BCBS MT HealthLink |
$958.68
|
| Rate for Payer: BCBS MT Medicare |
$958.68
|
| Rate for Payer: BCBS MT POS |
$1,011.94
|
| Rate for Payer: BCBS MT Traditional |
$1,065.20
|
| Rate for Payer: Cash Price |
$958.68
|
| Rate for Payer: Cigna Commercial |
$1,011.94
|
| Rate for Payer: Cigna Medicare |
$958.68
|
| Rate for Payer: Medicaid All Medicaid |
$979.98
|
| Rate for Payer: Medicare All Medicare |
$745.64
|
| Rate for Payer: Monida Allegiance |
$1,011.94
|
| Rate for Payer: Monida First Choice Health |
$1,033.24
|
| Rate for Payer: Monida Montana Health Co-op |
$1,011.94
|
| Rate for Payer: Monida PacificSource |
$1,011.94
|
|
|
BRIMONIDINE 0.2% (10 ML) OPTH DROPS
|
Facility
|
IP
|
$208.00
|
|
|
Service Code
|
NDC 61314014310
|
| Hospital Charge Code |
3007072
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$145.60 |
| Max. Negotiated Rate |
$208.00 |
| Rate for Payer: Aetna Commercial |
$197.60
|
| Rate for Payer: Aetna Medicare |
$187.20
|
| Rate for Payer: BCBS MT CHIP |
$187.20
|
| Rate for Payer: BCBS MT Closed Plan Network |
$197.60
|
| Rate for Payer: BCBS MT HealthLink |
$187.20
|
| Rate for Payer: BCBS MT Medicare |
$187.20
|
| Rate for Payer: BCBS MT POS |
$197.60
|
| Rate for Payer: BCBS MT Traditional |
$208.00
|
| Rate for Payer: Cash Price |
$187.20
|
| Rate for Payer: Cigna Commercial |
$197.60
|
| Rate for Payer: Cigna Medicare |
$187.20
|
| Rate for Payer: Medicaid All Medicaid |
$191.36
|
| Rate for Payer: Medicare All Medicare |
$145.60
|
| Rate for Payer: Monida Allegiance |
$197.60
|
| Rate for Payer: Monida First Choice Health |
$201.76
|
| Rate for Payer: Monida Montana Health Co-op |
$197.60
|
| Rate for Payer: Monida PacificSource |
$197.60
|
|
|
BRIMONIDINE 0.2% (10 ML) OPTH DROPS
|
Facility
|
OP
|
$208.00
|
|
|
Service Code
|
NDC 61314014310
|
| Hospital Charge Code |
3007072
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$145.60 |
| Max. Negotiated Rate |
$208.00 |
| Rate for Payer: Aetna Commercial |
$197.60
|
| Rate for Payer: Aetna Medicare |
$187.20
|
| Rate for Payer: BCBS MT CHIP |
$187.20
|
| Rate for Payer: BCBS MT Closed Plan Network |
$197.60
|
| Rate for Payer: BCBS MT HealthLink |
$187.20
|
| Rate for Payer: BCBS MT Medicare |
$187.20
|
| Rate for Payer: BCBS MT POS |
$197.60
|
| Rate for Payer: BCBS MT Traditional |
$208.00
|
| Rate for Payer: Cash Price |
$187.20
|
| Rate for Payer: Cigna Commercial |
$197.60
|
| Rate for Payer: Cigna Medicare |
$187.20
|
| Rate for Payer: Medicaid All Medicaid |
$191.36
|
| Rate for Payer: Medicare All Medicare |
$145.60
|
| Rate for Payer: Monida Allegiance |
$197.60
|
| Rate for Payer: Monida First Choice Health |
$201.76
|
| Rate for Payer: Monida Montana Health Co-op |
$197.60
|
| Rate for Payer: Monida PacificSource |
$197.60
|
|
