|
TR REMOVE IMPACTED CERUMEN
|
Facility
|
OP
|
$104.00
|
|
|
Service Code
|
HCPCS 69209
|
| Hospital Charge Code |
569209
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$72.80 |
| Max. Negotiated Rate |
$104.00 |
| Rate for Payer: Aetna Commercial |
$98.80
|
| Rate for Payer: Aetna Medicare |
$93.60
|
| Rate for Payer: BCBS MT CHIP |
$93.60
|
| Rate for Payer: BCBS MT Closed Plan Network |
$98.80
|
| Rate for Payer: BCBS MT HealthLink |
$93.60
|
| Rate for Payer: BCBS MT Medicare |
$93.60
|
| Rate for Payer: BCBS MT POS |
$98.80
|
| Rate for Payer: BCBS MT Traditional |
$104.00
|
| Rate for Payer: Cash Price |
$93.60
|
| Rate for Payer: Cigna Commercial |
$98.80
|
| Rate for Payer: Cigna Medicare |
$93.60
|
| Rate for Payer: Medicaid All Medicaid |
$95.68
|
| Rate for Payer: Medicare All Medicare |
$72.80
|
| Rate for Payer: Monida Allegiance |
$98.80
|
| Rate for Payer: Monida First Choice Health |
$100.88
|
| Rate for Payer: Monida Montana Health Co-op |
$98.80
|
| Rate for Payer: Monida PacificSource |
$98.80
|
|
|
TR REMOVE IMPACTED EAR WAX/INST
|
Facility
|
OP
|
$120.00
|
|
|
Service Code
|
HCPCS 69210
|
| Hospital Charge Code |
569210
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$84.00 |
| Max. Negotiated Rate |
$120.00 |
| Rate for Payer: Aetna Commercial |
$114.00
|
| Rate for Payer: Aetna Medicare |
$108.00
|
| Rate for Payer: BCBS MT CHIP |
$108.00
|
| Rate for Payer: BCBS MT Closed Plan Network |
$114.00
|
| Rate for Payer: BCBS MT HealthLink |
$108.00
|
| Rate for Payer: BCBS MT Medicare |
$108.00
|
| Rate for Payer: BCBS MT POS |
$114.00
|
| Rate for Payer: BCBS MT Traditional |
$120.00
|
| Rate for Payer: Cash Price |
$108.00
|
| Rate for Payer: Cigna Commercial |
$114.00
|
| Rate for Payer: Cigna Medicare |
$108.00
|
| Rate for Payer: Medicaid All Medicaid |
$110.40
|
| Rate for Payer: Medicare All Medicare |
$84.00
|
| Rate for Payer: Monida Allegiance |
$114.00
|
| Rate for Payer: Monida First Choice Health |
$116.40
|
| Rate for Payer: Monida Montana Health Co-op |
$114.00
|
| Rate for Payer: Monida PacificSource |
$114.00
|
|
|
TR REMOVE IMPACTED EAR WAX/INST
|
Facility
|
IP
|
$120.00
|
|
|
Service Code
|
HCPCS 69210
|
| Hospital Charge Code |
569210
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$84.00 |
| Max. Negotiated Rate |
$120.00 |
| Rate for Payer: Aetna Commercial |
$114.00
|
| Rate for Payer: Aetna Medicare |
$108.00
|
| Rate for Payer: BCBS MT CHIP |
$108.00
|
| Rate for Payer: BCBS MT Closed Plan Network |
$114.00
|
| Rate for Payer: BCBS MT HealthLink |
$108.00
|
| Rate for Payer: BCBS MT Medicare |
$108.00
|
| Rate for Payer: BCBS MT POS |
$114.00
|
| Rate for Payer: BCBS MT Traditional |
$120.00
|
| Rate for Payer: Cash Price |
$108.00
|
| Rate for Payer: Cigna Commercial |
$114.00
|
| Rate for Payer: Cigna Medicare |
$108.00
|
| Rate for Payer: Medicaid All Medicaid |
$110.40
|
| Rate for Payer: Medicare All Medicare |
$84.00
|
| Rate for Payer: Monida Allegiance |
$114.00
|
| Rate for Payer: Monida First Choice Health |
$116.40
|
| Rate for Payer: Monida Montana Health Co-op |
$114.00
|
| Rate for Payer: Monida PacificSource |
$114.00
|
|
|
TRYPTASE (004280)
|
Facility
|
OP
|
$263.00
|
|
|
Service Code
|
HCPCS 83520
|
| Hospital Charge Code |
4000057
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$184.10 |
| Max. Negotiated Rate |
$263.00 |
| Rate for Payer: Aetna Commercial |
$249.85
|
| Rate for Payer: Aetna Medicare |
$236.70
|
| Rate for Payer: BCBS MT CHIP |
$236.70
|
| Rate for Payer: BCBS MT Closed Plan Network |
$249.85
|
| Rate for Payer: BCBS MT HealthLink |
$236.70
|
| Rate for Payer: BCBS MT Medicare |
$236.70
|
| Rate for Payer: BCBS MT POS |
$249.85
|
| Rate for Payer: BCBS MT Traditional |
$263.00
|
| Rate for Payer: Cash Price |
$236.70
|
| Rate for Payer: Cigna Commercial |
$249.85
|
| Rate for Payer: Cigna Medicare |
$236.70
|
| Rate for Payer: Medicaid All Medicaid |
$241.96
|
| Rate for Payer: Medicare All Medicare |
$184.10
|
| Rate for Payer: Monida Allegiance |
$249.85
|
| Rate for Payer: Monida First Choice Health |
$255.11
|
| Rate for Payer: Monida Montana Health Co-op |
$249.85
|
| Rate for Payer: Monida PacificSource |
$249.85
|
|
|
TRYPTASE (004280)
|
Facility
|
IP
|
$263.00
|
|
|
Service Code
|
HCPCS 83520
|
| Hospital Charge Code |
4000057
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$184.10 |
| Max. Negotiated Rate |
$263.00 |
| Rate for Payer: Aetna Commercial |
$249.85
|
| Rate for Payer: Aetna Medicare |
$236.70
|
| Rate for Payer: BCBS MT CHIP |
$236.70
|
| Rate for Payer: BCBS MT Closed Plan Network |
$249.85
|
| Rate for Payer: BCBS MT HealthLink |
$236.70
|
| Rate for Payer: BCBS MT Medicare |
$236.70
|
| Rate for Payer: BCBS MT POS |
$249.85
|
| Rate for Payer: BCBS MT Traditional |
$263.00
|
| Rate for Payer: Cash Price |
$236.70
|
| Rate for Payer: Cigna Commercial |
$249.85
|
| Rate for Payer: Cigna Medicare |
$236.70
|
| Rate for Payer: Medicaid All Medicaid |
$241.96
|
| Rate for Payer: Medicare All Medicare |
$184.10
|
| Rate for Payer: Monida Allegiance |
$249.85
|
| Rate for Payer: Monida First Choice Health |
$255.11
|
| Rate for Payer: Monida Montana Health Co-op |
$249.85
|
| Rate for Payer: Monida PacificSource |
$249.85
|
|
|
TSH
|
Facility
|
IP
|
$167.00
|
|
|
Service Code
|
HCPCS 84443
|
| Hospital Charge Code |
4084443
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$116.90 |
| Max. Negotiated Rate |
$167.00 |
| Rate for Payer: Aetna Commercial |
$158.65
|
| Rate for Payer: Aetna Medicare |
$150.30
|
| Rate for Payer: BCBS MT CHIP |
$150.30
|
| Rate for Payer: BCBS MT Closed Plan Network |
$158.65
|
| Rate for Payer: BCBS MT HealthLink |
$150.30
|
| Rate for Payer: BCBS MT Medicare |
$150.30
|
| Rate for Payer: BCBS MT POS |
$158.65
|
| Rate for Payer: BCBS MT Traditional |
$167.00
|
| Rate for Payer: Cash Price |
$150.30
|
| Rate for Payer: Cigna Commercial |
$158.65
|
| Rate for Payer: Cigna Medicare |
$150.30
|
| Rate for Payer: Medicaid All Medicaid |
$153.64
|
| Rate for Payer: Medicare All Medicare |
$116.90
|
| Rate for Payer: Monida Allegiance |
$158.65
|
| Rate for Payer: Monida First Choice Health |
$161.99
|
| Rate for Payer: Monida Montana Health Co-op |
$158.65
|
| Rate for Payer: Monida PacificSource |
$158.65
|
|
|
TSH
|
Facility
|
OP
|
$167.00
|
|
|
Service Code
|
HCPCS 84443
|
| Hospital Charge Code |
4084443
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$116.90 |
| Max. Negotiated Rate |
$167.00 |
| Rate for Payer: Aetna Commercial |
$158.65
|
| Rate for Payer: Aetna Medicare |
$150.30
|
| Rate for Payer: BCBS MT CHIP |
$150.30
|
| Rate for Payer: BCBS MT Closed Plan Network |
$158.65
|
| Rate for Payer: BCBS MT HealthLink |
$150.30
|
| Rate for Payer: BCBS MT Medicare |
$150.30
|
| Rate for Payer: BCBS MT POS |
$158.65
|
| Rate for Payer: BCBS MT Traditional |
$167.00
|
| Rate for Payer: Cash Price |
$150.30
|
| Rate for Payer: Cigna Commercial |
$158.65
|
| Rate for Payer: Cigna Medicare |
$150.30
|
| Rate for Payer: Medicaid All Medicaid |
$153.64
|
| Rate for Payer: Medicare All Medicare |
$116.90
|
| Rate for Payer: Monida Allegiance |
$158.65
|
| Rate for Payer: Monida First Choice Health |
$161.99
|
| Rate for Payer: Monida Montana Health Co-op |
$158.65
|
| Rate for Payer: Monida PacificSource |
$158.65
|
|
|
TSH W/ REFLEX
|
Facility
|
OP
|
$167.00
|
|
|
Service Code
|
HCPCS 84443
|
| Hospital Charge Code |
4044431
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$116.90 |
| Max. Negotiated Rate |
$167.00 |
| Rate for Payer: Aetna Commercial |
$158.65
|
| Rate for Payer: Aetna Medicare |
$150.30
|
| Rate for Payer: BCBS MT CHIP |
$150.30
|
| Rate for Payer: BCBS MT Closed Plan Network |
$158.65
|
| Rate for Payer: BCBS MT HealthLink |
$150.30
|
| Rate for Payer: BCBS MT Medicare |
$150.30
|
| Rate for Payer: BCBS MT POS |
$158.65
|
| Rate for Payer: BCBS MT Traditional |
$167.00
|
| Rate for Payer: Cash Price |
$150.30
|
| Rate for Payer: Cigna Commercial |
$158.65
|
| Rate for Payer: Cigna Medicare |
$150.30
|
| Rate for Payer: Medicaid All Medicaid |
$153.64
|
| Rate for Payer: Medicare All Medicare |
$116.90
|
| Rate for Payer: Monida Allegiance |
$158.65
|
| Rate for Payer: Monida First Choice Health |
$161.99
|
| Rate for Payer: Monida Montana Health Co-op |
$158.65
|
| Rate for Payer: Monida PacificSource |
$158.65
|
|
|
TSH W/ REFLEX
|
Facility
|
IP
|
$167.00
|
|
|
Service Code
|
HCPCS 84443
|
| Hospital Charge Code |
4044431
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$116.90 |
| Max. Negotiated Rate |
$167.00 |
| Rate for Payer: Aetna Commercial |
$158.65
|
| Rate for Payer: Aetna Medicare |
$150.30
|
| Rate for Payer: BCBS MT CHIP |
$150.30
|
| Rate for Payer: BCBS MT Closed Plan Network |
$158.65
|
| Rate for Payer: BCBS MT HealthLink |
$150.30
|
| Rate for Payer: BCBS MT Medicare |
$150.30
|
| Rate for Payer: BCBS MT POS |
$158.65
|
| Rate for Payer: BCBS MT Traditional |
$167.00
|
| Rate for Payer: Cash Price |
$150.30
|
| Rate for Payer: Cigna Commercial |
$158.65
|
| Rate for Payer: Cigna Medicare |
$150.30
|
| Rate for Payer: Medicaid All Medicaid |
$153.64
|
| Rate for Payer: Medicare All Medicare |
$116.90
|
| Rate for Payer: Monida Allegiance |
$158.65
|
| Rate for Payer: Monida First Choice Health |
$161.99
|
| Rate for Payer: Monida Montana Health Co-op |
$158.65
|
| Rate for Payer: Monida PacificSource |
$158.65
|
|
|
TTG ANTIBODY, IGA (164640)
|
Facility
|
OP
|
$79.00
|
|
|
Service Code
|
HCPCS 86364
|
| Hospital Charge Code |
4000071
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$55.30 |
| Max. Negotiated Rate |
$79.00 |
| Rate for Payer: Aetna Commercial |
$75.05
|
| Rate for Payer: Aetna Medicare |
$71.10
|
| Rate for Payer: BCBS MT CHIP |
$71.10
|
| Rate for Payer: BCBS MT Closed Plan Network |
$75.05
|
| Rate for Payer: BCBS MT HealthLink |
$71.10
|
| Rate for Payer: BCBS MT Medicare |
$71.10
|
| Rate for Payer: BCBS MT POS |
$75.05
|
| Rate for Payer: BCBS MT Traditional |
$79.00
|
| Rate for Payer: Cash Price |
$71.10
|
| Rate for Payer: Cigna Commercial |
$75.05
|
| Rate for Payer: Cigna Medicare |
$71.10
|
| Rate for Payer: Medicaid All Medicaid |
$72.68
|
| Rate for Payer: Medicare All Medicare |
$55.30
|
| Rate for Payer: Monida Allegiance |
$75.05
|
| Rate for Payer: Monida First Choice Health |
$76.63
|
| Rate for Payer: Monida Montana Health Co-op |
$75.05
|
| Rate for Payer: Monida PacificSource |
$75.05
|
|
|
TTG ANTIBODY, IGA (164640)
|
Facility
|
IP
|
$79.00
|
|
|
Service Code
|
HCPCS 86364
|
| Hospital Charge Code |
4000071
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$55.30 |
| Max. Negotiated Rate |
$79.00 |
| Rate for Payer: Aetna Commercial |
$75.05
|
| Rate for Payer: Aetna Medicare |
$71.10
|
| Rate for Payer: BCBS MT CHIP |
$71.10
|
| Rate for Payer: BCBS MT Closed Plan Network |
$75.05
|
| Rate for Payer: BCBS MT HealthLink |
$71.10
|
| Rate for Payer: BCBS MT Medicare |
$71.10
|
| Rate for Payer: BCBS MT POS |
$75.05
|
| Rate for Payer: BCBS MT Traditional |
$79.00
|
| Rate for Payer: Cash Price |
$71.10
|
| Rate for Payer: Cigna Commercial |
$75.05
|
| Rate for Payer: Cigna Medicare |
$71.10
|
| Rate for Payer: Medicaid All Medicaid |
$72.68
|
| Rate for Payer: Medicare All Medicare |
$55.30
|
| Rate for Payer: Monida Allegiance |
$75.05
|
| Rate for Payer: Monida First Choice Health |
$76.63
|
| Rate for Payer: Monida Montana Health Co-op |
$75.05
|
| Rate for Payer: Monida PacificSource |
$75.05
|
|
|
TTG ANTIBODY, IGG (164988)
|
Facility
|
OP
|
$79.00
|
|
|
Service Code
|
HCPCS 86364
|
| Hospital Charge Code |
4000072
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$55.30 |
| Max. Negotiated Rate |
$79.00 |
| Rate for Payer: Aetna Commercial |
$75.05
|
| Rate for Payer: Aetna Medicare |
$71.10
|
| Rate for Payer: BCBS MT CHIP |
$71.10
|
| Rate for Payer: BCBS MT Closed Plan Network |
$75.05
|
| Rate for Payer: BCBS MT HealthLink |
$71.10
|
| Rate for Payer: BCBS MT Medicare |
$71.10
|
| Rate for Payer: BCBS MT POS |
$75.05
|
| Rate for Payer: BCBS MT Traditional |
$79.00
|
| Rate for Payer: Cash Price |
$71.10
|
| Rate for Payer: Cigna Commercial |
$75.05
|
| Rate for Payer: Cigna Medicare |
$71.10
|
| Rate for Payer: Medicaid All Medicaid |
$72.68
|
| Rate for Payer: Medicare All Medicare |
$55.30
|
| Rate for Payer: Monida Allegiance |
$75.05
|
| Rate for Payer: Monida First Choice Health |
$76.63
|
| Rate for Payer: Monida Montana Health Co-op |
$75.05
|
| Rate for Payer: Monida PacificSource |
$75.05
|
|
|
TTG ANTIBODY, IGG (164988)
|
Facility
|
IP
|
$79.00
|
|
|
Service Code
|
HCPCS 86364
|
| Hospital Charge Code |
4000072
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$55.30 |
| Max. Negotiated Rate |
$79.00 |
| Rate for Payer: Aetna Commercial |
$75.05
|
| Rate for Payer: Aetna Medicare |
$71.10
|
| Rate for Payer: BCBS MT CHIP |
$71.10
|
| Rate for Payer: BCBS MT Closed Plan Network |
$75.05
|
| Rate for Payer: BCBS MT HealthLink |
$71.10
|
| Rate for Payer: BCBS MT Medicare |
$71.10
|
| Rate for Payer: BCBS MT POS |
$75.05
|
| Rate for Payer: BCBS MT Traditional |
$79.00
|
| Rate for Payer: Cash Price |
$71.10
|
| Rate for Payer: Cigna Commercial |
$75.05
|
| Rate for Payer: Cigna Medicare |
$71.10
|
| Rate for Payer: Medicaid All Medicaid |
$72.68
|
| Rate for Payer: Medicare All Medicare |
$55.30
|
| Rate for Payer: Monida Allegiance |
$75.05
|
| Rate for Payer: Monida First Choice Health |
$76.63
|
| Rate for Payer: Monida Montana Health Co-op |
$75.05
|
| Rate for Payer: Monida PacificSource |
$75.05
|
|
|
TUBERCULOSIS TEST INTRADERMAL
|
Facility
|
IP
|
$56.00
|
|
|
Service Code
|
HCPCS 86580
|
| Hospital Charge Code |
3000492
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$39.20 |
| Max. Negotiated Rate |
$56.00 |
| Rate for Payer: Aetna Commercial |
$53.20
|
| Rate for Payer: Aetna Medicare |
$50.40
|
| Rate for Payer: BCBS MT CHIP |
$50.40
|
| Rate for Payer: BCBS MT Closed Plan Network |
$53.20
|
| Rate for Payer: BCBS MT HealthLink |
$50.40
|
| Rate for Payer: BCBS MT Medicare |
$50.40
|
| Rate for Payer: BCBS MT POS |
$53.20
|
| Rate for Payer: BCBS MT Traditional |
$56.00
|
| Rate for Payer: Cash Price |
$50.40
|
| Rate for Payer: Cigna Commercial |
$53.20
|
| Rate for Payer: Cigna Medicare |
$50.40
|
| Rate for Payer: Medicaid All Medicaid |
$51.52
|
| Rate for Payer: Medicare All Medicare |
$39.20
|
| Rate for Payer: Monida Allegiance |
$53.20
|
| Rate for Payer: Monida First Choice Health |
$54.32
|
| Rate for Payer: Monida Montana Health Co-op |
$53.20
|
| Rate for Payer: Monida PacificSource |
$53.20
|
|
|
TUBERCULOSIS TEST INTRADERMAL
|
Facility
|
OP
|
$56.00
|
|
|
Service Code
|
HCPCS 86580
|
| Hospital Charge Code |
3000492
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$39.20 |
| Max. Negotiated Rate |
$56.00 |
| Rate for Payer: Aetna Commercial |
$53.20
|
| Rate for Payer: Aetna Medicare |
$50.40
|
| Rate for Payer: BCBS MT CHIP |
$50.40
|
| Rate for Payer: BCBS MT Closed Plan Network |
$53.20
|
| Rate for Payer: BCBS MT HealthLink |
$50.40
|
| Rate for Payer: BCBS MT Medicare |
$50.40
|
| Rate for Payer: BCBS MT POS |
$53.20
|
| Rate for Payer: BCBS MT Traditional |
$56.00
|
| Rate for Payer: Cash Price |
$50.40
|
| Rate for Payer: Cigna Commercial |
$53.20
|
| Rate for Payer: Cigna Medicare |
$50.40
|
| Rate for Payer: Medicaid All Medicaid |
$51.52
|
| Rate for Payer: Medicare All Medicare |
$39.20
|
| Rate for Payer: Monida Allegiance |
$53.20
|
| Rate for Payer: Monida First Choice Health |
$54.32
|
| Rate for Payer: Monida Montana Health Co-op |
$53.20
|
| Rate for Payer: Monida PacificSource |
$53.20
|
|
|
TUBERSOL PPD INJ [5 TU/0.1 ML]
|
Facility
|
IP
|
$38.00
|
|
|
Service Code
|
HCPCS 86580
|
| Hospital Charge Code |
3000463
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$26.60 |
| Max. Negotiated Rate |
$38.00 |
| Rate for Payer: Aetna Commercial |
$36.10
|
| Rate for Payer: Aetna Medicare |
$34.20
|
| Rate for Payer: BCBS MT CHIP |
$34.20
|
| Rate for Payer: BCBS MT Closed Plan Network |
$36.10
|
| Rate for Payer: BCBS MT HealthLink |
$34.20
|
| Rate for Payer: BCBS MT Medicare |
$34.20
|
| Rate for Payer: BCBS MT POS |
$36.10
|
| Rate for Payer: BCBS MT Traditional |
$38.00
|
| Rate for Payer: Cash Price |
$34.20
|
| Rate for Payer: Cigna Commercial |
$36.10
|
| Rate for Payer: Cigna Medicare |
$34.20
|
| Rate for Payer: Medicaid All Medicaid |
$34.96
|
| Rate for Payer: Medicare All Medicare |
$26.60
|
| Rate for Payer: Monida Allegiance |
$36.10
|
| Rate for Payer: Monida First Choice Health |
$36.86
|
| Rate for Payer: Monida Montana Health Co-op |
$36.10
|
| Rate for Payer: Monida PacificSource |
$36.10
|
|
|
TUBERSOL PPD INJ [5 TU/0.1 ML]
|
Facility
|
OP
|
$38.00
|
|
|
Service Code
|
HCPCS 86580
|
| Hospital Charge Code |
3000463
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$26.60 |
| Max. Negotiated Rate |
$38.00 |
| Rate for Payer: Aetna Commercial |
$36.10
|
| Rate for Payer: Aetna Medicare |
$34.20
|
| Rate for Payer: BCBS MT CHIP |
$34.20
|
| Rate for Payer: BCBS MT Closed Plan Network |
$36.10
|
| Rate for Payer: BCBS MT HealthLink |
$34.20
|
| Rate for Payer: BCBS MT Medicare |
$34.20
|
| Rate for Payer: BCBS MT POS |
$36.10
|
| Rate for Payer: BCBS MT Traditional |
$38.00
|
| Rate for Payer: Cash Price |
$34.20
|
| Rate for Payer: Cigna Commercial |
$36.10
|
| Rate for Payer: Cigna Medicare |
$34.20
|
| Rate for Payer: Medicaid All Medicaid |
$34.96
|
| Rate for Payer: Medicare All Medicare |
$26.60
|
| Rate for Payer: Monida Allegiance |
$36.10
|
| Rate for Payer: Monida First Choice Health |
$36.86
|
| Rate for Payer: Monida Montana Health Co-op |
$36.10
|
| Rate for Payer: Monida PacificSource |
$36.10
|
|
|
TUBING FILTER
|
Facility
|
OP
|
$59.00
|
|
| Hospital Charge Code |
80030208
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$41.30 |
| Max. Negotiated Rate |
$59.00 |
| Rate for Payer: Aetna Commercial |
$56.05
|
| Rate for Payer: Aetna Medicare |
$53.10
|
| Rate for Payer: BCBS MT CHIP |
$53.10
|
| Rate for Payer: BCBS MT Closed Plan Network |
$56.05
|
| Rate for Payer: BCBS MT HealthLink |
$53.10
|
| Rate for Payer: BCBS MT Medicare |
$53.10
|
| Rate for Payer: BCBS MT POS |
$56.05
|
| Rate for Payer: BCBS MT Traditional |
$59.00
|
| Rate for Payer: Cash Price |
$53.10
|
| Rate for Payer: Cigna Commercial |
$56.05
|
| Rate for Payer: Cigna Medicare |
$53.10
|
| Rate for Payer: Medicaid All Medicaid |
$54.28
|
| Rate for Payer: Medicare All Medicare |
$41.30
|
| Rate for Payer: Monida Allegiance |
$56.05
|
| Rate for Payer: Monida First Choice Health |
$57.23
|
| Rate for Payer: Monida Montana Health Co-op |
$56.05
|
| Rate for Payer: Monida PacificSource |
$56.05
|
|
|
TUBING FILTER
|
Facility
|
IP
|
$59.00
|
|
| Hospital Charge Code |
80030208
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$41.30 |
| Max. Negotiated Rate |
$59.00 |
| Rate for Payer: Aetna Commercial |
$56.05
|
| Rate for Payer: Aetna Medicare |
$53.10
|
| Rate for Payer: BCBS MT CHIP |
$53.10
|
| Rate for Payer: BCBS MT Closed Plan Network |
$56.05
|
| Rate for Payer: BCBS MT HealthLink |
$53.10
|
| Rate for Payer: BCBS MT Medicare |
$53.10
|
| Rate for Payer: BCBS MT POS |
$56.05
|
| Rate for Payer: BCBS MT Traditional |
$59.00
|
| Rate for Payer: Cash Price |
$53.10
|
| Rate for Payer: Cigna Commercial |
$56.05
|
| Rate for Payer: Cigna Medicare |
$53.10
|
| Rate for Payer: Medicaid All Medicaid |
$54.28
|
| Rate for Payer: Medicare All Medicare |
$41.30
|
| Rate for Payer: Monida Allegiance |
$56.05
|
| Rate for Payer: Monida First Choice Health |
$57.23
|
| Rate for Payer: Monida Montana Health Co-op |
$56.05
|
| Rate for Payer: Monida PacificSource |
$56.05
|
|
|
TUBING PRIMARY HOSPIRA PLUM
|
Facility
|
IP
|
$27.00
|
|
| Hospital Charge Code |
80030897
|
|
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
|
|
|
TUBING PRIMARY HOSPIRA PLUM
|
Facility
|
OP
|
$27.00
|
|
| Hospital Charge Code |
80030897
|
|
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
|
|
|
TUBING SECONDARY HOSPIRA PLUM
|
Facility
|
OP
|
$13.00
|
|
| Hospital Charge Code |
90030898
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$9.10 |
| Max. Negotiated Rate |
$13.00 |
| Rate for Payer: Aetna Commercial |
$12.35
|
| Rate for Payer: Aetna Medicare |
$11.70
|
| Rate for Payer: BCBS MT CHIP |
$11.70
|
| Rate for Payer: BCBS MT Closed Plan Network |
$12.35
|
| Rate for Payer: BCBS MT HealthLink |
$11.70
|
| Rate for Payer: BCBS MT Medicare |
$11.70
|
| Rate for Payer: BCBS MT POS |
$12.35
|
| Rate for Payer: BCBS MT Traditional |
$13.00
|
| Rate for Payer: Cash Price |
$11.70
|
| Rate for Payer: Cigna Commercial |
$12.35
|
| Rate for Payer: Cigna Medicare |
$11.70
|
| Rate for Payer: Medicaid All Medicaid |
$11.96
|
| Rate for Payer: Medicare All Medicare |
$9.10
|
| Rate for Payer: Monida Allegiance |
$12.35
|
| Rate for Payer: Monida First Choice Health |
$12.61
|
| Rate for Payer: Monida Montana Health Co-op |
$12.35
|
| Rate for Payer: Monida PacificSource |
$12.35
|
|
|
TUBING SECONDARY HOSPIRA PLUM
|
Facility
|
IP
|
$13.00
|
|
| Hospital Charge Code |
90030898
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$9.10 |
| Max. Negotiated Rate |
$13.00 |
| Rate for Payer: Aetna Commercial |
$12.35
|
| Rate for Payer: Aetna Medicare |
$11.70
|
| Rate for Payer: BCBS MT CHIP |
$11.70
|
| Rate for Payer: BCBS MT Closed Plan Network |
$12.35
|
| Rate for Payer: BCBS MT HealthLink |
$11.70
|
| Rate for Payer: BCBS MT Medicare |
$11.70
|
| Rate for Payer: BCBS MT POS |
$12.35
|
| Rate for Payer: BCBS MT Traditional |
$13.00
|
| Rate for Payer: Cash Price |
$11.70
|
| Rate for Payer: Cigna Commercial |
$12.35
|
| Rate for Payer: Cigna Medicare |
$11.70
|
| Rate for Payer: Medicaid All Medicaid |
$11.96
|
| Rate for Payer: Medicare All Medicare |
$9.10
|
| Rate for Payer: Monida Allegiance |
$12.35
|
| Rate for Payer: Monida First Choice Health |
$12.61
|
| Rate for Payer: Monida Montana Health Co-op |
$12.35
|
| Rate for Payer: Monida PacificSource |
$12.35
|
|
|
TUCKS MEDICATED COOLING PADS
|
Facility
|
OP
|
$12.45
|
|
|
Service Code
|
NDC 41388000732
|
| Hospital Charge Code |
3007354
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.72 |
| Max. Negotiated Rate |
$12.45 |
| Rate for Payer: Aetna Commercial |
$11.83
|
| Rate for Payer: Aetna Medicare |
$11.20
|
| Rate for Payer: BCBS MT CHIP |
$11.20
|
| Rate for Payer: BCBS MT Closed Plan Network |
$11.83
|
| Rate for Payer: BCBS MT HealthLink |
$11.20
|
| Rate for Payer: BCBS MT Medicare |
$11.20
|
| Rate for Payer: BCBS MT POS |
$11.83
|
| Rate for Payer: BCBS MT Traditional |
$12.45
|
| Rate for Payer: Cash Price |
$11.21
|
| Rate for Payer: Cigna Commercial |
$11.83
|
| Rate for Payer: Cigna Medicare |
$11.20
|
| Rate for Payer: Medicaid All Medicaid |
$11.45
|
| Rate for Payer: Medicare All Medicare |
$8.72
|
| Rate for Payer: Monida Allegiance |
$11.83
|
| Rate for Payer: Monida First Choice Health |
$12.08
|
| Rate for Payer: Monida Montana Health Co-op |
$11.83
|
| Rate for Payer: Monida PacificSource |
$11.83
|
|
|
TUCKS MEDICATED COOLING PADS
|
Facility
|
IP
|
$12.45
|
|
|
Service Code
|
NDC 41388000732
|
| Hospital Charge Code |
3007354
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.72 |
| Max. Negotiated Rate |
$12.45 |
| Rate for Payer: Aetna Commercial |
$11.83
|
| Rate for Payer: Aetna Medicare |
$11.20
|
| Rate for Payer: BCBS MT CHIP |
$11.20
|
| Rate for Payer: BCBS MT Closed Plan Network |
$11.83
|
| Rate for Payer: BCBS MT HealthLink |
$11.20
|
| Rate for Payer: BCBS MT Medicare |
$11.20
|
| Rate for Payer: BCBS MT POS |
$11.83
|
| Rate for Payer: BCBS MT Traditional |
$12.45
|
| Rate for Payer: Cash Price |
$11.21
|
| Rate for Payer: Cigna Commercial |
$11.83
|
| Rate for Payer: Cigna Medicare |
$11.20
|
| Rate for Payer: Medicaid All Medicaid |
$11.45
|
| Rate for Payer: Medicare All Medicare |
$8.72
|
| Rate for Payer: Monida Allegiance |
$11.83
|
| Rate for Payer: Monida First Choice Health |
$12.08
|
| Rate for Payer: Monida Montana Health Co-op |
$11.83
|
| Rate for Payer: Monida PacificSource |
$11.83
|
|
