|
POSTVASECTOMY SPERM EVALUATION
|
Facility
|
OP
|
$85.00
|
|
|
Service Code
|
CPT 89321
|
| Hospital Charge Code |
4089321
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$59.50 |
| Max. Negotiated Rate |
$85.00 |
| Rate for Payer: Aetna Commercial |
$80.75
|
| Rate for Payer: Aetna Medicare |
$76.50
|
| Rate for Payer: BCBS MT CHIP |
$76.50
|
| Rate for Payer: BCBS MT Closed Plan Network |
$80.75
|
| Rate for Payer: BCBS MT HealthLink |
$76.50
|
| Rate for Payer: BCBS MT Medicare |
$76.50
|
| Rate for Payer: BCBS MT POS |
$80.75
|
| Rate for Payer: BCBS MT Traditional |
$85.00
|
| Rate for Payer: Cash Price |
$76.50
|
| Rate for Payer: Cigna Commercial |
$80.75
|
| Rate for Payer: Cigna Medicare |
$76.50
|
| Rate for Payer: Medicaid All Medicaid |
$78.20
|
| Rate for Payer: Medicare All Medicare |
$59.50
|
| Rate for Payer: Monida Allegiance |
$80.75
|
| Rate for Payer: Monida First Choice Health |
$82.45
|
| Rate for Payer: Monida Montana Health Co-op |
$80.75
|
| Rate for Payer: Monida PacificSource |
$80.75
|
|
|
POSTVASECTOMY SPERM EVALUATION
|
Facility
|
IP
|
$85.00
|
|
|
Service Code
|
CPT 89321
|
| Hospital Charge Code |
4089321
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$59.50 |
| Max. Negotiated Rate |
$85.00 |
| Rate for Payer: Aetna Commercial |
$80.75
|
| Rate for Payer: Aetna Medicare |
$76.50
|
| Rate for Payer: BCBS MT CHIP |
$76.50
|
| Rate for Payer: BCBS MT Closed Plan Network |
$80.75
|
| Rate for Payer: BCBS MT HealthLink |
$76.50
|
| Rate for Payer: BCBS MT Medicare |
$76.50
|
| Rate for Payer: BCBS MT POS |
$80.75
|
| Rate for Payer: BCBS MT Traditional |
$85.00
|
| Rate for Payer: Cash Price |
$76.50
|
| Rate for Payer: Cigna Commercial |
$80.75
|
| Rate for Payer: Cigna Medicare |
$76.50
|
| Rate for Payer: Medicaid All Medicaid |
$78.20
|
| Rate for Payer: Medicare All Medicare |
$59.50
|
| Rate for Payer: Monida Allegiance |
$80.75
|
| Rate for Payer: Monida First Choice Health |
$82.45
|
| Rate for Payer: Monida Montana Health Co-op |
$80.75
|
| Rate for Payer: Monida PacificSource |
$80.75
|
|
|
POTASSIUM
|
Facility
|
IP
|
$63.00
|
|
|
Service Code
|
CPT 84132
|
| Hospital Charge Code |
4084132
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$44.10 |
| Max. Negotiated Rate |
$63.00 |
| Rate for Payer: Aetna Commercial |
$59.85
|
| Rate for Payer: Aetna Medicare |
$56.70
|
| Rate for Payer: BCBS MT CHIP |
$56.70
|
| Rate for Payer: BCBS MT Closed Plan Network |
$59.85
|
| Rate for Payer: BCBS MT HealthLink |
$56.70
|
| Rate for Payer: BCBS MT Medicare |
$56.70
|
| Rate for Payer: BCBS MT POS |
$59.85
|
| Rate for Payer: BCBS MT Traditional |
$63.00
|
| Rate for Payer: Cash Price |
$56.70
|
| Rate for Payer: Cigna Commercial |
$59.85
|
| Rate for Payer: Cigna Medicare |
$56.70
|
| Rate for Payer: Medicaid All Medicaid |
$57.96
|
| Rate for Payer: Medicare All Medicare |
$44.10
|
| Rate for Payer: Monida Allegiance |
$59.85
|
| Rate for Payer: Monida First Choice Health |
$61.11
|
| Rate for Payer: Monida Montana Health Co-op |
$59.85
|
| Rate for Payer: Monida PacificSource |
$59.85
|
|
|
POTASSIUM
|
Facility
|
OP
|
$63.00
|
|
|
Service Code
|
CPT 84132
|
| Hospital Charge Code |
4084132
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$44.10 |
| Max. Negotiated Rate |
$63.00 |
| Rate for Payer: Aetna Commercial |
$59.85
|
| Rate for Payer: Aetna Medicare |
$56.70
|
| Rate for Payer: BCBS MT CHIP |
$56.70
|
| Rate for Payer: BCBS MT Closed Plan Network |
$59.85
|
| Rate for Payer: BCBS MT HealthLink |
$56.70
|
| Rate for Payer: BCBS MT Medicare |
$56.70
|
| Rate for Payer: BCBS MT POS |
$59.85
|
| Rate for Payer: BCBS MT Traditional |
$63.00
|
| Rate for Payer: Cash Price |
$56.70
|
| Rate for Payer: Cigna Commercial |
$59.85
|
| Rate for Payer: Cigna Medicare |
$56.70
|
| Rate for Payer: Medicaid All Medicaid |
$57.96
|
| Rate for Payer: Medicare All Medicare |
$44.10
|
| Rate for Payer: Monida Allegiance |
$59.85
|
| Rate for Payer: Monida First Choice Health |
$61.11
|
| Rate for Payer: Monida Montana Health Co-op |
$59.85
|
| Rate for Payer: Monida PacificSource |
$59.85
|
|
|
POTASSIUM, 24 HOUR URINE
|
Facility
|
IP
|
$66.00
|
|
|
Service Code
|
CPT 84133
|
| Hospital Charge Code |
4088000
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$46.20 |
| Max. Negotiated Rate |
$66.00 |
| Rate for Payer: Aetna Commercial |
$62.70
|
| Rate for Payer: Aetna Medicare |
$59.40
|
| Rate for Payer: BCBS MT CHIP |
$59.40
|
| Rate for Payer: BCBS MT Closed Plan Network |
$62.70
|
| Rate for Payer: BCBS MT HealthLink |
$59.40
|
| Rate for Payer: BCBS MT Medicare |
$59.40
|
| Rate for Payer: BCBS MT POS |
$62.70
|
| Rate for Payer: BCBS MT Traditional |
$66.00
|
| Rate for Payer: Cash Price |
$59.40
|
| Rate for Payer: Cigna Commercial |
$62.70
|
| Rate for Payer: Cigna Medicare |
$59.40
|
| Rate for Payer: Medicaid All Medicaid |
$60.72
|
| Rate for Payer: Medicare All Medicare |
$46.20
|
| Rate for Payer: Monida Allegiance |
$62.70
|
| Rate for Payer: Monida First Choice Health |
$64.02
|
| Rate for Payer: Monida Montana Health Co-op |
$62.70
|
| Rate for Payer: Monida PacificSource |
$62.70
|
|
|
POTASSIUM, 24 HOUR URINE
|
Facility
|
OP
|
$66.00
|
|
|
Service Code
|
CPT 84133
|
| Hospital Charge Code |
4088000
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$46.20 |
| Max. Negotiated Rate |
$66.00 |
| Rate for Payer: Aetna Commercial |
$62.70
|
| Rate for Payer: Aetna Medicare |
$59.40
|
| Rate for Payer: BCBS MT CHIP |
$59.40
|
| Rate for Payer: BCBS MT Closed Plan Network |
$62.70
|
| Rate for Payer: BCBS MT HealthLink |
$59.40
|
| Rate for Payer: BCBS MT Medicare |
$59.40
|
| Rate for Payer: BCBS MT POS |
$62.70
|
| Rate for Payer: BCBS MT Traditional |
$66.00
|
| Rate for Payer: Cash Price |
$59.40
|
| Rate for Payer: Cigna Commercial |
$62.70
|
| Rate for Payer: Cigna Medicare |
$59.40
|
| Rate for Payer: Medicaid All Medicaid |
$60.72
|
| Rate for Payer: Medicare All Medicare |
$46.20
|
| Rate for Payer: Monida Allegiance |
$62.70
|
| Rate for Payer: Monida First Choice Health |
$64.02
|
| Rate for Payer: Monida Montana Health Co-op |
$62.70
|
| Rate for Payer: Monida PacificSource |
$62.70
|
|
|
POTASSIUM CL PACKET [20 MEQ]
|
Facility
|
IP
|
$36.00
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
3000392
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$25.20 |
| Max. Negotiated Rate |
$36.00 |
| Rate for Payer: Aetna Commercial |
$34.20
|
| Rate for Payer: Aetna Medicare |
$32.40
|
| Rate for Payer: BCBS MT CHIP |
$32.40
|
| Rate for Payer: BCBS MT Closed Plan Network |
$34.20
|
| Rate for Payer: BCBS MT HealthLink |
$32.40
|
| Rate for Payer: BCBS MT Medicare |
$32.40
|
| Rate for Payer: BCBS MT POS |
$34.20
|
| Rate for Payer: BCBS MT Traditional |
$36.00
|
| Rate for Payer: Cash Price |
$32.40
|
| Rate for Payer: Cigna Commercial |
$34.20
|
| Rate for Payer: Cigna Medicare |
$32.40
|
| Rate for Payer: Medicaid All Medicaid |
$33.12
|
| Rate for Payer: Medicare All Medicare |
$25.20
|
| Rate for Payer: Monida Allegiance |
$34.20
|
| Rate for Payer: Monida First Choice Health |
$34.92
|
| Rate for Payer: Monida Montana Health Co-op |
$34.20
|
| Rate for Payer: Monida PacificSource |
$34.20
|
|
|
POTASSIUM CL PACKET [20 MEQ]
|
Facility
|
OP
|
$36.00
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
3000392
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$25.20 |
| Max. Negotiated Rate |
$36.00 |
| Rate for Payer: Aetna Commercial |
$34.20
|
| Rate for Payer: Aetna Medicare |
$32.40
|
| Rate for Payer: BCBS MT CHIP |
$32.40
|
| Rate for Payer: BCBS MT Closed Plan Network |
$34.20
|
| Rate for Payer: BCBS MT HealthLink |
$32.40
|
| Rate for Payer: BCBS MT Medicare |
$32.40
|
| Rate for Payer: BCBS MT POS |
$34.20
|
| Rate for Payer: BCBS MT Traditional |
$36.00
|
| Rate for Payer: Cash Price |
$32.40
|
| Rate for Payer: Cigna Commercial |
$34.20
|
| Rate for Payer: Cigna Medicare |
$32.40
|
| Rate for Payer: Medicaid All Medicaid |
$33.12
|
| Rate for Payer: Medicare All Medicare |
$25.20
|
| Rate for Payer: Monida Allegiance |
$34.20
|
| Rate for Payer: Monida First Choice Health |
$34.92
|
| Rate for Payer: Monida Montana Health Co-op |
$34.20
|
| Rate for Payer: Monida PacificSource |
$34.20
|
|
|
POTASSIUM CL TAB [10 MEQ] NF
|
Facility
|
IP
|
$8.00
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
3000393
|
|
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
|
|
|
POTASSIUM CL TAB [10 MEQ] NF
|
Facility
|
OP
|
$8.00
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
3000393
|
|
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
|
|
|
POTASSIUM CL TAB [20 MEQ]
|
Facility
|
OP
|
$8.00
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
3000394
|
|
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
|
|
|
POTASSIUM CL TAB [20 MEQ]
|
Facility
|
IP
|
$8.00
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
3000394
|
|
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
|
|
|
POTASSIUM, RANDOM URINE (013334)
|
Facility
|
OP
|
$56.00
|
|
|
Service Code
|
CPT 84133
|
| Hospital Charge Code |
4084133
|
|
Hospital Revenue Code
|
300
|
| 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
|
|
|
POTASSIUM, RANDOM URINE (013334)
|
Facility
|
IP
|
$56.00
|
|
|
Service Code
|
CPT 84133
|
| Hospital Charge Code |
4084133
|
|
Hospital Revenue Code
|
300
|
| 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
|
|
|
POVIDONE-IODINE SOLN [10 %] 4OZ BTL
|
Facility
|
OP
|
$8.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
3000395
|
|
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
|
|
|
POVIDONE-IODINE SOLN [10 %] 4OZ BTL
|
Facility
|
IP
|
$8.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
3000395
|
|
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
|
|
|
POVIDONE IODINE SWAB STICKS
|
Facility
|
OP
|
$5.00
|
|
| Hospital Charge Code |
80030422
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$3.50 |
| Max. Negotiated Rate |
$5.00 |
| Rate for Payer: Aetna Commercial |
$4.75
|
| Rate for Payer: Aetna Medicare |
$4.50
|
| Rate for Payer: BCBS MT CHIP |
$4.50
|
| Rate for Payer: BCBS MT Closed Plan Network |
$4.75
|
| Rate for Payer: BCBS MT HealthLink |
$4.50
|
| Rate for Payer: BCBS MT Medicare |
$4.50
|
| Rate for Payer: BCBS MT POS |
$4.75
|
| Rate for Payer: BCBS MT Traditional |
$5.00
|
| Rate for Payer: Cash Price |
$4.50
|
| Rate for Payer: Cigna Commercial |
$4.75
|
| Rate for Payer: Cigna Medicare |
$4.50
|
| Rate for Payer: Medicaid All Medicaid |
$4.60
|
| Rate for Payer: Medicare All Medicare |
$3.50
|
| Rate for Payer: Monida Allegiance |
$4.75
|
| Rate for Payer: Monida First Choice Health |
$4.85
|
| Rate for Payer: Monida Montana Health Co-op |
$4.75
|
| Rate for Payer: Monida PacificSource |
$4.75
|
|
|
POVIDONE IODINE SWAB STICKS
|
Facility
|
IP
|
$5.00
|
|
| Hospital Charge Code |
80030422
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$3.50 |
| Max. Negotiated Rate |
$5.00 |
| Rate for Payer: Aetna Commercial |
$4.75
|
| Rate for Payer: Aetna Medicare |
$4.50
|
| Rate for Payer: BCBS MT CHIP |
$4.50
|
| Rate for Payer: BCBS MT Closed Plan Network |
$4.75
|
| Rate for Payer: BCBS MT HealthLink |
$4.50
|
| Rate for Payer: BCBS MT Medicare |
$4.50
|
| Rate for Payer: BCBS MT POS |
$4.75
|
| Rate for Payer: BCBS MT Traditional |
$5.00
|
| Rate for Payer: Cash Price |
$4.50
|
| Rate for Payer: Cigna Commercial |
$4.75
|
| Rate for Payer: Cigna Medicare |
$4.50
|
| Rate for Payer: Medicaid All Medicaid |
$4.60
|
| Rate for Payer: Medicare All Medicare |
$3.50
|
| Rate for Payer: Monida Allegiance |
$4.75
|
| Rate for Payer: Monida First Choice Health |
$4.85
|
| Rate for Payer: Monida Montana Health Co-op |
$4.75
|
| Rate for Payer: Monida PacificSource |
$4.75
|
|
|
POV PROLONGED SERVICE OV-OP 1ST HR
|
Facility
|
OP
|
$301.00
|
|
|
Service Code
|
CPT 99354
|
| Hospital Charge Code |
8099354
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$210.70 |
| Max. Negotiated Rate |
$301.00 |
| Rate for Payer: Aetna Commercial |
$285.95
|
| Rate for Payer: Aetna Medicare |
$270.90
|
| Rate for Payer: BCBS MT CHIP |
$270.90
|
| Rate for Payer: BCBS MT Closed Plan Network |
$285.95
|
| Rate for Payer: BCBS MT HealthLink |
$270.90
|
| Rate for Payer: BCBS MT Medicare |
$270.90
|
| Rate for Payer: BCBS MT POS |
$285.95
|
| Rate for Payer: BCBS MT Traditional |
$301.00
|
| Rate for Payer: Cash Price |
$270.90
|
| Rate for Payer: Cigna Commercial |
$285.95
|
| Rate for Payer: Cigna Medicare |
$270.90
|
| Rate for Payer: Medicaid All Medicaid |
$276.92
|
| Rate for Payer: Medicare All Medicare |
$210.70
|
| Rate for Payer: Monida Allegiance |
$285.95
|
| Rate for Payer: Monida First Choice Health |
$291.97
|
| Rate for Payer: Monida Montana Health Co-op |
$285.95
|
| Rate for Payer: Monida PacificSource |
$285.95
|
|
|
POV PROLONGED SERVICE OV-OP 1ST HR
|
Facility
|
IP
|
$301.00
|
|
|
Service Code
|
CPT 99354
|
| Hospital Charge Code |
8099354
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$210.70 |
| Max. Negotiated Rate |
$301.00 |
| Rate for Payer: Aetna Commercial |
$285.95
|
| Rate for Payer: Aetna Medicare |
$270.90
|
| Rate for Payer: BCBS MT CHIP |
$270.90
|
| Rate for Payer: BCBS MT Closed Plan Network |
$285.95
|
| Rate for Payer: BCBS MT HealthLink |
$270.90
|
| Rate for Payer: BCBS MT Medicare |
$270.90
|
| Rate for Payer: BCBS MT POS |
$285.95
|
| Rate for Payer: BCBS MT Traditional |
$301.00
|
| Rate for Payer: Cash Price |
$270.90
|
| Rate for Payer: Cigna Commercial |
$285.95
|
| Rate for Payer: Cigna Medicare |
$270.90
|
| Rate for Payer: Medicaid All Medicaid |
$276.92
|
| Rate for Payer: Medicare All Medicare |
$210.70
|
| Rate for Payer: Monida Allegiance |
$285.95
|
| Rate for Payer: Monida First Choice Health |
$291.97
|
| Rate for Payer: Monida Montana Health Co-op |
$285.95
|
| Rate for Payer: Monida PacificSource |
$285.95
|
|
|
POV PROLONGED SERVICE OV-OP EA30MIN
|
Facility
|
OP
|
$231.00
|
|
|
Service Code
|
CPT 99355
|
| Hospital Charge Code |
8099355
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$161.70 |
| Max. Negotiated Rate |
$231.00 |
| Rate for Payer: Aetna Commercial |
$219.45
|
| Rate for Payer: Aetna Medicare |
$207.90
|
| Rate for Payer: BCBS MT CHIP |
$207.90
|
| Rate for Payer: BCBS MT Closed Plan Network |
$219.45
|
| Rate for Payer: BCBS MT HealthLink |
$207.90
|
| Rate for Payer: BCBS MT Medicare |
$207.90
|
| Rate for Payer: BCBS MT POS |
$219.45
|
| Rate for Payer: BCBS MT Traditional |
$231.00
|
| Rate for Payer: Cash Price |
$207.90
|
| Rate for Payer: Cigna Commercial |
$219.45
|
| Rate for Payer: Cigna Medicare |
$207.90
|
| Rate for Payer: Medicaid All Medicaid |
$212.52
|
| Rate for Payer: Medicare All Medicare |
$161.70
|
| Rate for Payer: Monida Allegiance |
$219.45
|
| Rate for Payer: Monida First Choice Health |
$224.07
|
| Rate for Payer: Monida Montana Health Co-op |
$219.45
|
| Rate for Payer: Monida PacificSource |
$219.45
|
|
|
POV PROLONGED SERVICE OV-OP EA30MIN
|
Facility
|
IP
|
$231.00
|
|
|
Service Code
|
CPT 99355
|
| Hospital Charge Code |
8099355
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$161.70 |
| Max. Negotiated Rate |
$231.00 |
| Rate for Payer: Aetna Commercial |
$219.45
|
| Rate for Payer: Aetna Medicare |
$207.90
|
| Rate for Payer: BCBS MT CHIP |
$207.90
|
| Rate for Payer: BCBS MT Closed Plan Network |
$219.45
|
| Rate for Payer: BCBS MT HealthLink |
$207.90
|
| Rate for Payer: BCBS MT Medicare |
$207.90
|
| Rate for Payer: BCBS MT POS |
$219.45
|
| Rate for Payer: BCBS MT Traditional |
$231.00
|
| Rate for Payer: Cash Price |
$207.90
|
| Rate for Payer: Cigna Commercial |
$219.45
|
| Rate for Payer: Cigna Medicare |
$207.90
|
| Rate for Payer: Medicaid All Medicaid |
$212.52
|
| Rate for Payer: Medicare All Medicare |
$161.70
|
| Rate for Payer: Monida Allegiance |
$219.45
|
| Rate for Payer: Monida First Choice Health |
$224.07
|
| Rate for Payer: Monida Montana Health Co-op |
$219.45
|
| Rate for Payer: Monida PacificSource |
$219.45
|
|
|
PRAMIPEXOLE [0.25MG] TAB
|
Facility
|
IP
|
$8.00
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
3000396
|
|
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
|
|
|
PRAMIPEXOLE [0.25MG] TAB
|
Facility
|
OP
|
$8.00
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
3000396
|
|
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
|
|
|
PRAMIPEXOLE TAB [0.25 MG] NF
|
Facility
|
OP
|
$8.00
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
3000616
|
|
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
|
|
