|
SKIN SUBS APPLIC T,A,L EA 25 SQCM 15272
|
Facility
|
OP
|
$493.00
|
|
|
Service Code
|
HCPCS 15272
|
| Hospital Charge Code |
8015272
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$345.10 |
| Max. Negotiated Rate |
$493.00 |
| Rate for Payer: Aetna Commercial |
$468.35
|
| Rate for Payer: Aetna Medicare |
$443.70
|
| Rate for Payer: BCBS MT CHIP |
$443.70
|
| Rate for Payer: BCBS MT Closed Plan Network |
$468.35
|
| Rate for Payer: BCBS MT HealthLink |
$443.70
|
| Rate for Payer: BCBS MT Medicare |
$443.70
|
| Rate for Payer: BCBS MT POS |
$468.35
|
| Rate for Payer: BCBS MT Traditional |
$493.00
|
| Rate for Payer: Cash Price |
$443.70
|
| Rate for Payer: Cigna Commercial |
$468.35
|
| Rate for Payer: Cigna Medicare |
$443.70
|
| Rate for Payer: Medicaid All Medicaid |
$453.56
|
| Rate for Payer: Medicare All Medicare |
$345.10
|
| Rate for Payer: Monida Allegiance |
$468.35
|
| Rate for Payer: Monida First Choice Health |
$478.21
|
| Rate for Payer: Monida Montana Health Co-op |
$468.35
|
| Rate for Payer: Monida PacificSource |
$468.35
|
|
|
SKIN SUBS APPLIC T,A,L EA 25 SQCM 15272
|
Facility
|
IP
|
$493.00
|
|
|
Service Code
|
HCPCS 15272
|
| Hospital Charge Code |
8015272
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$345.10 |
| Max. Negotiated Rate |
$493.00 |
| Rate for Payer: Aetna Commercial |
$468.35
|
| Rate for Payer: Aetna Medicare |
$443.70
|
| Rate for Payer: BCBS MT CHIP |
$443.70
|
| Rate for Payer: BCBS MT Closed Plan Network |
$468.35
|
| Rate for Payer: BCBS MT HealthLink |
$443.70
|
| Rate for Payer: BCBS MT Medicare |
$443.70
|
| Rate for Payer: BCBS MT POS |
$468.35
|
| Rate for Payer: BCBS MT Traditional |
$493.00
|
| Rate for Payer: Cash Price |
$443.70
|
| Rate for Payer: Cigna Commercial |
$468.35
|
| Rate for Payer: Cigna Medicare |
$443.70
|
| Rate for Payer: Medicaid All Medicaid |
$453.56
|
| Rate for Payer: Medicare All Medicare |
$345.10
|
| Rate for Payer: Monida Allegiance |
$468.35
|
| Rate for Payer: Monida First Choice Health |
$478.21
|
| Rate for Payer: Monida Montana Health Co-op |
$468.35
|
| Rate for Payer: Monida PacificSource |
$468.35
|
|
|
SLING AND SWATHE LG
|
Facility
|
IP
|
$37.00
|
|
| Hospital Charge Code |
2893511
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$25.90 |
| Max. Negotiated Rate |
$37.00 |
| Rate for Payer: Aetna Commercial |
$35.15
|
| Rate for Payer: Aetna Medicare |
$33.30
|
| Rate for Payer: BCBS MT CHIP |
$33.30
|
| Rate for Payer: BCBS MT Closed Plan Network |
$35.15
|
| Rate for Payer: BCBS MT HealthLink |
$33.30
|
| Rate for Payer: BCBS MT Medicare |
$33.30
|
| Rate for Payer: BCBS MT POS |
$35.15
|
| Rate for Payer: BCBS MT Traditional |
$37.00
|
| Rate for Payer: Cash Price |
$33.30
|
| Rate for Payer: Cigna Commercial |
$35.15
|
| Rate for Payer: Cigna Medicare |
$33.30
|
| Rate for Payer: Medicaid All Medicaid |
$34.04
|
| Rate for Payer: Medicare All Medicare |
$25.90
|
| Rate for Payer: Monida Allegiance |
$35.15
|
| Rate for Payer: Monida First Choice Health |
$35.89
|
| Rate for Payer: Monida Montana Health Co-op |
$35.15
|
| Rate for Payer: Monida PacificSource |
$35.15
|
|
|
SLING AND SWATHE LG
|
Facility
|
OP
|
$37.00
|
|
| Hospital Charge Code |
2893511
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$25.90 |
| Max. Negotiated Rate |
$37.00 |
| Rate for Payer: Aetna Commercial |
$35.15
|
| Rate for Payer: Aetna Medicare |
$33.30
|
| Rate for Payer: BCBS MT CHIP |
$33.30
|
| Rate for Payer: BCBS MT Closed Plan Network |
$35.15
|
| Rate for Payer: BCBS MT HealthLink |
$33.30
|
| Rate for Payer: BCBS MT Medicare |
$33.30
|
| Rate for Payer: BCBS MT POS |
$35.15
|
| Rate for Payer: BCBS MT Traditional |
$37.00
|
| Rate for Payer: Cash Price |
$33.30
|
| Rate for Payer: Cigna Commercial |
$35.15
|
| Rate for Payer: Cigna Medicare |
$33.30
|
| Rate for Payer: Medicaid All Medicaid |
$34.04
|
| Rate for Payer: Medicare All Medicare |
$25.90
|
| Rate for Payer: Monida Allegiance |
$35.15
|
| Rate for Payer: Monida First Choice Health |
$35.89
|
| Rate for Payer: Monida Montana Health Co-op |
$35.15
|
| Rate for Payer: Monida PacificSource |
$35.15
|
|
|
SLING AND SWATHE MD
|
Facility
|
OP
|
$37.00
|
|
| Hospital Charge Code |
2893510
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$25.90 |
| Max. Negotiated Rate |
$37.00 |
| Rate for Payer: Aetna Commercial |
$35.15
|
| Rate for Payer: Aetna Medicare |
$33.30
|
| Rate for Payer: BCBS MT CHIP |
$33.30
|
| Rate for Payer: BCBS MT Closed Plan Network |
$35.15
|
| Rate for Payer: BCBS MT HealthLink |
$33.30
|
| Rate for Payer: BCBS MT Medicare |
$33.30
|
| Rate for Payer: BCBS MT POS |
$35.15
|
| Rate for Payer: BCBS MT Traditional |
$37.00
|
| Rate for Payer: Cash Price |
$33.30
|
| Rate for Payer: Cigna Commercial |
$35.15
|
| Rate for Payer: Cigna Medicare |
$33.30
|
| Rate for Payer: Medicaid All Medicaid |
$34.04
|
| Rate for Payer: Medicare All Medicare |
$25.90
|
| Rate for Payer: Monida Allegiance |
$35.15
|
| Rate for Payer: Monida First Choice Health |
$35.89
|
| Rate for Payer: Monida Montana Health Co-op |
$35.15
|
| Rate for Payer: Monida PacificSource |
$35.15
|
|
|
SLING AND SWATHE MD
|
Facility
|
IP
|
$37.00
|
|
| Hospital Charge Code |
2893510
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$25.90 |
| Max. Negotiated Rate |
$37.00 |
| Rate for Payer: Aetna Commercial |
$35.15
|
| Rate for Payer: Aetna Medicare |
$33.30
|
| Rate for Payer: BCBS MT CHIP |
$33.30
|
| Rate for Payer: BCBS MT Closed Plan Network |
$35.15
|
| Rate for Payer: BCBS MT HealthLink |
$33.30
|
| Rate for Payer: BCBS MT Medicare |
$33.30
|
| Rate for Payer: BCBS MT POS |
$35.15
|
| Rate for Payer: BCBS MT Traditional |
$37.00
|
| Rate for Payer: Cash Price |
$33.30
|
| Rate for Payer: Cigna Commercial |
$35.15
|
| Rate for Payer: Cigna Medicare |
$33.30
|
| Rate for Payer: Medicaid All Medicaid |
$34.04
|
| Rate for Payer: Medicare All Medicare |
$25.90
|
| Rate for Payer: Monida Allegiance |
$35.15
|
| Rate for Payer: Monida First Choice Health |
$35.89
|
| Rate for Payer: Monida Montana Health Co-op |
$35.15
|
| Rate for Payer: Monida PacificSource |
$35.15
|
|
|
SLING AND SWATHE SM
|
Facility
|
OP
|
$43.00
|
|
| Hospital Charge Code |
2840095
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$30.10 |
| Max. Negotiated Rate |
$43.00 |
| Rate for Payer: Aetna Commercial |
$40.85
|
| Rate for Payer: Aetna Medicare |
$38.70
|
| Rate for Payer: BCBS MT CHIP |
$38.70
|
| Rate for Payer: BCBS MT Closed Plan Network |
$40.85
|
| Rate for Payer: BCBS MT HealthLink |
$38.70
|
| Rate for Payer: BCBS MT Medicare |
$38.70
|
| Rate for Payer: BCBS MT POS |
$40.85
|
| Rate for Payer: BCBS MT Traditional |
$43.00
|
| Rate for Payer: Cash Price |
$38.70
|
| Rate for Payer: Cigna Commercial |
$40.85
|
| Rate for Payer: Cigna Medicare |
$38.70
|
| Rate for Payer: Medicaid All Medicaid |
$39.56
|
| Rate for Payer: Medicare All Medicare |
$30.10
|
| Rate for Payer: Monida Allegiance |
$40.85
|
| Rate for Payer: Monida First Choice Health |
$41.71
|
| Rate for Payer: Monida Montana Health Co-op |
$40.85
|
| Rate for Payer: Monida PacificSource |
$40.85
|
|
|
SLING AND SWATHE SM
|
Facility
|
IP
|
$43.00
|
|
| Hospital Charge Code |
2840095
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$30.10 |
| Max. Negotiated Rate |
$43.00 |
| Rate for Payer: Aetna Commercial |
$40.85
|
| Rate for Payer: Aetna Medicare |
$38.70
|
| Rate for Payer: BCBS MT CHIP |
$38.70
|
| Rate for Payer: BCBS MT Closed Plan Network |
$40.85
|
| Rate for Payer: BCBS MT HealthLink |
$38.70
|
| Rate for Payer: BCBS MT Medicare |
$38.70
|
| Rate for Payer: BCBS MT POS |
$40.85
|
| Rate for Payer: BCBS MT Traditional |
$43.00
|
| Rate for Payer: Cash Price |
$38.70
|
| Rate for Payer: Cigna Commercial |
$40.85
|
| Rate for Payer: Cigna Medicare |
$38.70
|
| Rate for Payer: Medicaid All Medicaid |
$39.56
|
| Rate for Payer: Medicare All Medicare |
$30.10
|
| Rate for Payer: Monida Allegiance |
$40.85
|
| Rate for Payer: Monida First Choice Health |
$41.71
|
| Rate for Payer: Monida Montana Health Co-op |
$40.85
|
| Rate for Payer: Monida PacificSource |
$40.85
|
|
|
SMALLBORE EXTENSION SET
|
Facility
|
IP
|
$35.00
|
|
| Hospital Charge Code |
80030040
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$24.50 |
| Max. Negotiated Rate |
$35.00 |
| Rate for Payer: Aetna Commercial |
$33.25
|
| Rate for Payer: Aetna Medicare |
$31.50
|
| Rate for Payer: BCBS MT CHIP |
$31.50
|
| Rate for Payer: BCBS MT Closed Plan Network |
$33.25
|
| Rate for Payer: BCBS MT HealthLink |
$31.50
|
| Rate for Payer: BCBS MT Medicare |
$31.50
|
| Rate for Payer: BCBS MT POS |
$33.25
|
| Rate for Payer: BCBS MT Traditional |
$35.00
|
| Rate for Payer: Cash Price |
$31.50
|
| Rate for Payer: Cigna Commercial |
$33.25
|
| Rate for Payer: Cigna Medicare |
$31.50
|
| Rate for Payer: Medicaid All Medicaid |
$32.20
|
| Rate for Payer: Medicare All Medicare |
$24.50
|
| Rate for Payer: Monida Allegiance |
$33.25
|
| Rate for Payer: Monida First Choice Health |
$33.95
|
| Rate for Payer: Monida Montana Health Co-op |
$33.25
|
| Rate for Payer: Monida PacificSource |
$33.25
|
|
|
SMALLBORE EXTENSION SET
|
Facility
|
OP
|
$35.00
|
|
| Hospital Charge Code |
80030040
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$24.50 |
| Max. Negotiated Rate |
$35.00 |
| Rate for Payer: Aetna Commercial |
$33.25
|
| Rate for Payer: Aetna Medicare |
$31.50
|
| Rate for Payer: BCBS MT CHIP |
$31.50
|
| Rate for Payer: BCBS MT Closed Plan Network |
$33.25
|
| Rate for Payer: BCBS MT HealthLink |
$31.50
|
| Rate for Payer: BCBS MT Medicare |
$31.50
|
| Rate for Payer: BCBS MT POS |
$33.25
|
| Rate for Payer: BCBS MT Traditional |
$35.00
|
| Rate for Payer: Cash Price |
$31.50
|
| Rate for Payer: Cigna Commercial |
$33.25
|
| Rate for Payer: Cigna Medicare |
$31.50
|
| Rate for Payer: Medicaid All Medicaid |
$32.20
|
| Rate for Payer: Medicare All Medicare |
$24.50
|
| Rate for Payer: Monida Allegiance |
$33.25
|
| Rate for Payer: Monida First Choice Health |
$33.95
|
| Rate for Payer: Monida Montana Health Co-op |
$33.25
|
| Rate for Payer: Monida PacificSource |
$33.25
|
|
|
SMITH ANTIBODIES (016360)
|
Facility
|
OP
|
$114.00
|
|
|
Service Code
|
HCPCS 86235
|
| Hospital Charge Code |
4000065
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$79.80 |
| Max. Negotiated Rate |
$114.00 |
| Rate for Payer: Aetna Commercial |
$108.30
|
| Rate for Payer: Aetna Medicare |
$102.60
|
| Rate for Payer: BCBS MT CHIP |
$102.60
|
| Rate for Payer: BCBS MT Closed Plan Network |
$108.30
|
| Rate for Payer: BCBS MT HealthLink |
$102.60
|
| Rate for Payer: BCBS MT Medicare |
$102.60
|
| Rate for Payer: BCBS MT POS |
$108.30
|
| Rate for Payer: BCBS MT Traditional |
$114.00
|
| Rate for Payer: Cash Price |
$102.60
|
| Rate for Payer: Cigna Commercial |
$108.30
|
| Rate for Payer: Cigna Medicare |
$102.60
|
| Rate for Payer: Medicaid All Medicaid |
$104.88
|
| Rate for Payer: Medicare All Medicare |
$79.80
|
| Rate for Payer: Monida Allegiance |
$108.30
|
| Rate for Payer: Monida First Choice Health |
$110.58
|
| Rate for Payer: Monida Montana Health Co-op |
$108.30
|
| Rate for Payer: Monida PacificSource |
$108.30
|
|
|
SMITH ANTIBODIES (016360)
|
Facility
|
IP
|
$114.00
|
|
|
Service Code
|
HCPCS 86235
|
| Hospital Charge Code |
4000065
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$79.80 |
| Max. Negotiated Rate |
$114.00 |
| Rate for Payer: Aetna Commercial |
$108.30
|
| Rate for Payer: Aetna Medicare |
$102.60
|
| Rate for Payer: BCBS MT CHIP |
$102.60
|
| Rate for Payer: BCBS MT Closed Plan Network |
$108.30
|
| Rate for Payer: BCBS MT HealthLink |
$102.60
|
| Rate for Payer: BCBS MT Medicare |
$102.60
|
| Rate for Payer: BCBS MT POS |
$108.30
|
| Rate for Payer: BCBS MT Traditional |
$114.00
|
| Rate for Payer: Cash Price |
$102.60
|
| Rate for Payer: Cigna Commercial |
$108.30
|
| Rate for Payer: Cigna Medicare |
$102.60
|
| Rate for Payer: Medicaid All Medicaid |
$104.88
|
| Rate for Payer: Medicare All Medicare |
$79.80
|
| Rate for Payer: Monida Allegiance |
$108.30
|
| Rate for Payer: Monida First Choice Health |
$110.58
|
| Rate for Payer: Monida Montana Health Co-op |
$108.30
|
| Rate for Payer: Monida PacificSource |
$108.30
|
|
|
SODIUM
|
Facility
|
IP
|
$53.00
|
|
|
Service Code
|
HCPCS 84295
|
| Hospital Charge Code |
4084295
|
|
Hospital Revenue Code
|
301
|
| 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
|
|
|
SODIUM
|
Facility
|
OP
|
$53.00
|
|
|
Service Code
|
HCPCS 84295
|
| Hospital Charge Code |
4084295
|
|
Hospital Revenue Code
|
301
|
| 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
|
|
|
SODIUM BICARB INJ 4.2% [5MEQ/10ML] PEDS
|
Facility
|
IP
|
$50.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
3000427
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$35.00 |
| Max. Negotiated Rate |
$50.00 |
| Rate for Payer: Aetna Commercial |
$47.50
|
| Rate for Payer: Aetna Medicare |
$45.00
|
| Rate for Payer: BCBS MT CHIP |
$45.00
|
| Rate for Payer: BCBS MT Closed Plan Network |
$47.50
|
| Rate for Payer: BCBS MT HealthLink |
$45.00
|
| Rate for Payer: BCBS MT Medicare |
$45.00
|
| Rate for Payer: BCBS MT POS |
$47.50
|
| Rate for Payer: BCBS MT Traditional |
$50.00
|
| Rate for Payer: Cash Price |
$45.00
|
| Rate for Payer: Cigna Commercial |
$47.50
|
| Rate for Payer: Cigna Medicare |
$45.00
|
| Rate for Payer: Medicaid All Medicaid |
$46.00
|
| Rate for Payer: Medicare All Medicare |
$35.00
|
| Rate for Payer: Monida Allegiance |
$47.50
|
| Rate for Payer: Monida First Choice Health |
$48.50
|
| Rate for Payer: Monida Montana Health Co-op |
$47.50
|
| Rate for Payer: Monida PacificSource |
$47.50
|
|
|
SODIUM BICARB INJ 4.2% [5MEQ/10ML] PEDS
|
Facility
|
OP
|
$50.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
3000427
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$35.00 |
| Max. Negotiated Rate |
$50.00 |
| Rate for Payer: Aetna Commercial |
$47.50
|
| Rate for Payer: Aetna Medicare |
$45.00
|
| Rate for Payer: BCBS MT CHIP |
$45.00
|
| Rate for Payer: BCBS MT Closed Plan Network |
$47.50
|
| Rate for Payer: BCBS MT HealthLink |
$45.00
|
| Rate for Payer: BCBS MT Medicare |
$45.00
|
| Rate for Payer: BCBS MT POS |
$47.50
|
| Rate for Payer: BCBS MT Traditional |
$50.00
|
| Rate for Payer: Cash Price |
$45.00
|
| Rate for Payer: Cigna Commercial |
$47.50
|
| Rate for Payer: Cigna Medicare |
$45.00
|
| Rate for Payer: Medicaid All Medicaid |
$46.00
|
| Rate for Payer: Medicare All Medicare |
$35.00
|
| Rate for Payer: Monida Allegiance |
$47.50
|
| Rate for Payer: Monida First Choice Health |
$48.50
|
| Rate for Payer: Monida Montana Health Co-op |
$47.50
|
| Rate for Payer: Monida PacificSource |
$47.50
|
|
|
SODIUM BICARB INJ 8.4% [50 MEQ/50 ML]
|
Facility
|
OP
|
$65.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
3000428
|
|
Hospital Revenue Code
|
259
|
| 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
|
|
|
SODIUM BICARB INJ 8.4% [50 MEQ/50 ML]
|
Facility
|
IP
|
$65.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
3000428
|
|
Hospital Revenue Code
|
259
|
| 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
|
|
|
SODIUM BICARBONATE TAB [650 MG] NF
|
Facility
|
IP
|
$8.00
|
|
|
Service Code
|
NDC 77333082725
|
| Hospital Charge Code |
3007397
|
|
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
|
|
|
SODIUM BICARBONATE TAB [650 MG] NF
|
Facility
|
OP
|
$8.00
|
|
|
Service Code
|
NDC 77333082725
|
| Hospital Charge Code |
3007397
|
|
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
|
|
|
SODIUM CHLORIDE 0.9% NEB SOLN [3 ML]
|
Facility
|
IP
|
$8.00
|
|
|
Service Code
|
HCPCS A4216
|
| Hospital Charge Code |
3000429
|
|
Hospital Revenue Code
|
259
|
| 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
|
|
|
SODIUM CHLORIDE 0.9% NEB SOLN [3 ML]
|
Facility
|
OP
|
$8.00
|
|
|
Service Code
|
HCPCS A4216
|
| Hospital Charge Code |
3000429
|
|
Hospital Revenue Code
|
259
|
| 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
|
|
|
SODIUM CHLORIDE MOISTURIZING NASAL SPRAY
|
Facility
|
OP
|
$8.00
|
|
|
Service Code
|
NDC 00904386575
|
| Hospital Charge Code |
3007353
|
|
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
|
|
|
SODIUM CHLORIDE MOISTURIZING NASAL SPRAY
|
Facility
|
IP
|
$8.00
|
|
|
Service Code
|
NDC 00904386575
|
| Hospital Charge Code |
3007353
|
|
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
|
|
|
SODIUM CHLORIDE SOLN INH 7% 4 ML
|
Facility
|
IP
|
$57.60
|
|
|
Service Code
|
NDC 83490030760
|
| Hospital Charge Code |
3007360
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$40.32 |
| Max. Negotiated Rate |
$57.60 |
| Rate for Payer: Aetna Commercial |
$54.72
|
| Rate for Payer: Aetna Medicare |
$51.84
|
| Rate for Payer: BCBS MT CHIP |
$51.84
|
| Rate for Payer: BCBS MT Closed Plan Network |
$54.72
|
| Rate for Payer: BCBS MT HealthLink |
$51.84
|
| Rate for Payer: BCBS MT Medicare |
$51.84
|
| Rate for Payer: BCBS MT POS |
$54.72
|
| Rate for Payer: BCBS MT Traditional |
$57.60
|
| Rate for Payer: Cash Price |
$51.84
|
| Rate for Payer: Cigna Commercial |
$54.72
|
| Rate for Payer: Cigna Medicare |
$51.84
|
| Rate for Payer: Medicaid All Medicaid |
$52.99
|
| Rate for Payer: Medicare All Medicare |
$40.32
|
| Rate for Payer: Monida Allegiance |
$54.72
|
| Rate for Payer: Monida First Choice Health |
$55.87
|
| Rate for Payer: Monida Montana Health Co-op |
$54.72
|
| Rate for Payer: Monida PacificSource |
$54.72
|
|
