|
ABBOTT FENTANYL QC
|
Facility
|
IP
|
$55.46
|
|
| Hospital Charge Code |
90197150
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$38.82 |
| Max. Negotiated Rate |
$55.46 |
| Rate for Payer: Aetna Commercial |
$52.69
|
| Rate for Payer: Aetna Medicare |
$49.91
|
| Rate for Payer: BCBS MT CHIP |
$49.91
|
| Rate for Payer: BCBS MT Closed Plan Network |
$52.69
|
| Rate for Payer: BCBS MT HealthLink |
$49.91
|
| Rate for Payer: BCBS MT Medicare |
$49.91
|
| Rate for Payer: BCBS MT POS |
$52.69
|
| Rate for Payer: BCBS MT Traditional |
$55.46
|
| Rate for Payer: Cash Price |
$49.91
|
| Rate for Payer: Cigna Commercial |
$52.69
|
| Rate for Payer: Cigna Medicare |
$49.91
|
| Rate for Payer: Medicaid All Medicaid |
$51.02
|
| Rate for Payer: Medicare All Medicare |
$38.82
|
| Rate for Payer: Monida Allegiance |
$52.69
|
| Rate for Payer: Monida First Choice Health |
$53.80
|
| Rate for Payer: Monida Montana Health Co-op |
$52.69
|
| Rate for Payer: Monida PacificSource |
$52.69
|
|
|
ABBOTT HIV AG/AB RVMC
|
Facility
|
IP
|
$84.00
|
|
|
Service Code
|
CPT 87389
|
| Hospital Charge Code |
4087892
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$58.80 |
| Max. Negotiated Rate |
$84.00 |
| Rate for Payer: Aetna Commercial |
$79.80
|
| Rate for Payer: Aetna Medicare |
$75.60
|
| Rate for Payer: BCBS MT CHIP |
$75.60
|
| Rate for Payer: BCBS MT Closed Plan Network |
$79.80
|
| Rate for Payer: BCBS MT HealthLink |
$75.60
|
| Rate for Payer: BCBS MT Medicare |
$75.60
|
| Rate for Payer: BCBS MT POS |
$79.80
|
| Rate for Payer: BCBS MT Traditional |
$84.00
|
| Rate for Payer: Cash Price |
$75.60
|
| Rate for Payer: Cigna Commercial |
$79.80
|
| Rate for Payer: Cigna Medicare |
$75.60
|
| Rate for Payer: Medicaid All Medicaid |
$77.28
|
| Rate for Payer: Medicare All Medicare |
$58.80
|
| Rate for Payer: Monida Allegiance |
$79.80
|
| Rate for Payer: Monida First Choice Health |
$81.48
|
| Rate for Payer: Monida Montana Health Co-op |
$79.80
|
| Rate for Payer: Monida PacificSource |
$79.80
|
|
|
ABBOTT HIV AG/AB RVMC
|
Facility
|
OP
|
$84.00
|
|
|
Service Code
|
CPT 87389
|
| Hospital Charge Code |
4087892
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$58.80 |
| Max. Negotiated Rate |
$84.00 |
| Rate for Payer: Aetna Commercial |
$79.80
|
| Rate for Payer: Aetna Medicare |
$75.60
|
| Rate for Payer: BCBS MT CHIP |
$75.60
|
| Rate for Payer: BCBS MT Closed Plan Network |
$79.80
|
| Rate for Payer: BCBS MT HealthLink |
$75.60
|
| Rate for Payer: BCBS MT Medicare |
$75.60
|
| Rate for Payer: BCBS MT POS |
$79.80
|
| Rate for Payer: BCBS MT Traditional |
$84.00
|
| Rate for Payer: Cash Price |
$75.60
|
| Rate for Payer: Cigna Commercial |
$79.80
|
| Rate for Payer: Cigna Medicare |
$75.60
|
| Rate for Payer: Medicaid All Medicaid |
$77.28
|
| Rate for Payer: Medicare All Medicare |
$58.80
|
| Rate for Payer: Monida Allegiance |
$79.80
|
| Rate for Payer: Monida First Choice Health |
$81.48
|
| Rate for Payer: Monida Montana Health Co-op |
$79.80
|
| Rate for Payer: Monida PacificSource |
$79.80
|
|
|
ABDOMINA L BINDER
|
Facility
|
OP
|
$51.00
|
|
| Hospital Charge Code |
2820000
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$35.70 |
| Max. Negotiated Rate |
$51.00 |
| Rate for Payer: Aetna Commercial |
$48.45
|
| Rate for Payer: Aetna Medicare |
$45.90
|
| Rate for Payer: BCBS MT CHIP |
$45.90
|
| Rate for Payer: BCBS MT Closed Plan Network |
$48.45
|
| Rate for Payer: BCBS MT HealthLink |
$45.90
|
| Rate for Payer: BCBS MT Medicare |
$45.90
|
| Rate for Payer: BCBS MT POS |
$48.45
|
| Rate for Payer: BCBS MT Traditional |
$51.00
|
| Rate for Payer: Cash Price |
$45.90
|
| Rate for Payer: Cigna Commercial |
$48.45
|
| Rate for Payer: Cigna Medicare |
$45.90
|
| Rate for Payer: Medicaid All Medicaid |
$46.92
|
| Rate for Payer: Medicare All Medicare |
$35.70
|
| Rate for Payer: Monida Allegiance |
$48.45
|
| Rate for Payer: Monida First Choice Health |
$49.47
|
| Rate for Payer: Monida Montana Health Co-op |
$48.45
|
| Rate for Payer: Monida PacificSource |
$48.45
|
|
|
ABDOMINA L BINDER
|
Facility
|
IP
|
$51.00
|
|
| Hospital Charge Code |
2820000
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$35.70 |
| Max. Negotiated Rate |
$51.00 |
| Rate for Payer: Aetna Commercial |
$48.45
|
| Rate for Payer: Aetna Medicare |
$45.90
|
| Rate for Payer: BCBS MT CHIP |
$45.90
|
| Rate for Payer: BCBS MT Closed Plan Network |
$48.45
|
| Rate for Payer: BCBS MT HealthLink |
$45.90
|
| Rate for Payer: BCBS MT Medicare |
$45.90
|
| Rate for Payer: BCBS MT POS |
$48.45
|
| Rate for Payer: BCBS MT Traditional |
$51.00
|
| Rate for Payer: Cash Price |
$45.90
|
| Rate for Payer: Cigna Commercial |
$48.45
|
| Rate for Payer: Cigna Medicare |
$45.90
|
| Rate for Payer: Medicaid All Medicaid |
$46.92
|
| Rate for Payer: Medicare All Medicare |
$35.70
|
| Rate for Payer: Monida Allegiance |
$48.45
|
| Rate for Payer: Monida First Choice Health |
$49.47
|
| Rate for Payer: Monida Montana Health Co-op |
$48.45
|
| Rate for Payer: Monida PacificSource |
$48.45
|
|
|
ABDOMINAL BINDER 10'' X-LG
|
Facility
|
OP
|
$43.00
|
|
| Hospital Charge Code |
2840217
|
|
Hospital Revenue Code
|
290
|
| 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
|
|
|
ABDOMINAL BINDER 10'' X-LG
|
Facility
|
IP
|
$43.00
|
|
| Hospital Charge Code |
2840217
|
|
Hospital Revenue Code
|
290
|
| 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
|
|
|
ABO TYPE
|
Facility
|
OP
|
$109.00
|
|
|
Service Code
|
CPT 86900
|
| Hospital Charge Code |
4086900
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$76.30 |
| Max. Negotiated Rate |
$109.00 |
| Rate for Payer: Aetna Commercial |
$103.55
|
| Rate for Payer: Aetna Medicare |
$98.10
|
| Rate for Payer: BCBS MT CHIP |
$98.10
|
| Rate for Payer: BCBS MT Closed Plan Network |
$103.55
|
| Rate for Payer: BCBS MT HealthLink |
$98.10
|
| Rate for Payer: BCBS MT Medicare |
$98.10
|
| Rate for Payer: BCBS MT POS |
$103.55
|
| Rate for Payer: BCBS MT Traditional |
$109.00
|
| Rate for Payer: Cash Price |
$98.10
|
| Rate for Payer: Cigna Commercial |
$103.55
|
| Rate for Payer: Cigna Medicare |
$98.10
|
| Rate for Payer: Medicaid All Medicaid |
$100.28
|
| Rate for Payer: Medicare All Medicare |
$76.30
|
| Rate for Payer: Monida Allegiance |
$103.55
|
| Rate for Payer: Monida First Choice Health |
$105.73
|
| Rate for Payer: Monida Montana Health Co-op |
$103.55
|
| Rate for Payer: Monida PacificSource |
$103.55
|
|
|
ABO TYPE
|
Facility
|
IP
|
$109.00
|
|
|
Service Code
|
CPT 86900
|
| Hospital Charge Code |
4086900
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$76.30 |
| Max. Negotiated Rate |
$109.00 |
| Rate for Payer: Aetna Commercial |
$103.55
|
| Rate for Payer: Aetna Medicare |
$98.10
|
| Rate for Payer: BCBS MT CHIP |
$98.10
|
| Rate for Payer: BCBS MT Closed Plan Network |
$103.55
|
| Rate for Payer: BCBS MT HealthLink |
$98.10
|
| Rate for Payer: BCBS MT Medicare |
$98.10
|
| Rate for Payer: BCBS MT POS |
$103.55
|
| Rate for Payer: BCBS MT Traditional |
$109.00
|
| Rate for Payer: Cash Price |
$98.10
|
| Rate for Payer: Cigna Commercial |
$103.55
|
| Rate for Payer: Cigna Medicare |
$98.10
|
| Rate for Payer: Medicaid All Medicaid |
$100.28
|
| Rate for Payer: Medicare All Medicare |
$76.30
|
| Rate for Payer: Monida Allegiance |
$103.55
|
| Rate for Payer: Monida First Choice Health |
$105.73
|
| Rate for Payer: Monida Montana Health Co-op |
$103.55
|
| Rate for Payer: Monida PacificSource |
$103.55
|
|
|
ABSOLUTE CD4/CD8 COUNT W/ RATIO (505271)
|
Facility
|
OP
|
$131.00
|
|
|
Service Code
|
CPT 86360
|
| Hospital Charge Code |
4086360
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$91.70 |
| Max. Negotiated Rate |
$131.00 |
| Rate for Payer: Aetna Commercial |
$124.45
|
| Rate for Payer: Aetna Medicare |
$117.90
|
| Rate for Payer: BCBS MT CHIP |
$117.90
|
| Rate for Payer: BCBS MT Closed Plan Network |
$124.45
|
| Rate for Payer: BCBS MT HealthLink |
$117.90
|
| Rate for Payer: BCBS MT Medicare |
$117.90
|
| Rate for Payer: BCBS MT POS |
$124.45
|
| Rate for Payer: BCBS MT Traditional |
$131.00
|
| Rate for Payer: Cash Price |
$117.90
|
| Rate for Payer: Cigna Commercial |
$124.45
|
| Rate for Payer: Cigna Medicare |
$117.90
|
| Rate for Payer: Medicaid All Medicaid |
$120.52
|
| Rate for Payer: Medicare All Medicare |
$91.70
|
| Rate for Payer: Monida Allegiance |
$124.45
|
| Rate for Payer: Monida First Choice Health |
$127.07
|
| Rate for Payer: Monida Montana Health Co-op |
$124.45
|
| Rate for Payer: Monida PacificSource |
$124.45
|
|
|
ABSOLUTE CD4/CD8 COUNT W/ RATIO (505271)
|
Facility
|
IP
|
$131.00
|
|
|
Service Code
|
CPT 86360
|
| Hospital Charge Code |
4086360
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$91.70 |
| Max. Negotiated Rate |
$131.00 |
| Rate for Payer: Aetna Commercial |
$124.45
|
| Rate for Payer: Aetna Medicare |
$117.90
|
| Rate for Payer: BCBS MT CHIP |
$117.90
|
| Rate for Payer: BCBS MT Closed Plan Network |
$124.45
|
| Rate for Payer: BCBS MT HealthLink |
$117.90
|
| Rate for Payer: BCBS MT Medicare |
$117.90
|
| Rate for Payer: BCBS MT POS |
$124.45
|
| Rate for Payer: BCBS MT Traditional |
$131.00
|
| Rate for Payer: Cash Price |
$117.90
|
| Rate for Payer: Cigna Commercial |
$124.45
|
| Rate for Payer: Cigna Medicare |
$117.90
|
| Rate for Payer: Medicaid All Medicaid |
$120.52
|
| Rate for Payer: Medicare All Medicare |
$91.70
|
| Rate for Payer: Monida Allegiance |
$124.45
|
| Rate for Payer: Monida First Choice Health |
$127.07
|
| Rate for Payer: Monida Montana Health Co-op |
$124.45
|
| Rate for Payer: Monida PacificSource |
$124.45
|
|
|
ACE BANDAGE < 3
|
Facility
|
IP
|
$5.00
|
|
|
Service Code
|
HCPCS A6448
|
| Hospital Charge Code |
8006448
|
|
Hospital Revenue Code
|
290
|
| 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
|
|
|
ACE BANDAGE < 3
|
Facility
|
OP
|
$5.00
|
|
|
Service Code
|
HCPCS A6448
|
| Hospital Charge Code |
8006448
|
|
Hospital Revenue Code
|
290
|
| 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
|
|
|
ACE BANDAGE 3-5
|
Facility
|
IP
|
$5.00
|
|
|
Service Code
|
HCPCS A6449
|
| Hospital Charge Code |
8006449
|
|
Hospital Revenue Code
|
290
|
| 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
|
|
|
ACE BANDAGE 3-5
|
Facility
|
OP
|
$5.00
|
|
|
Service Code
|
HCPCS A6449
|
| Hospital Charge Code |
8006449
|
|
Hospital Revenue Code
|
290
|
| 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
|
|
|
ACE BANDAGE 3' W/VELCRO
|
Facility
|
IP
|
$1.00
|
|
|
Service Code
|
HCPCS A4590
|
| Hospital Charge Code |
2830020
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$0.70 |
| Max. Negotiated Rate |
$1.00 |
| Rate for Payer: Aetna Commercial |
$0.95
|
| Rate for Payer: Aetna Medicare |
$0.90
|
| Rate for Payer: BCBS MT CHIP |
$0.90
|
| Rate for Payer: BCBS MT Closed Plan Network |
$0.95
|
| Rate for Payer: BCBS MT HealthLink |
$0.90
|
| Rate for Payer: BCBS MT Medicare |
$0.90
|
| Rate for Payer: BCBS MT POS |
$0.95
|
| Rate for Payer: BCBS MT Traditional |
$1.00
|
| Rate for Payer: Cash Price |
$0.90
|
| Rate for Payer: Cigna Commercial |
$0.95
|
| Rate for Payer: Cigna Medicare |
$0.90
|
| Rate for Payer: Medicaid All Medicaid |
$0.92
|
| Rate for Payer: Medicare All Medicare |
$0.70
|
| Rate for Payer: Monida Allegiance |
$0.95
|
| Rate for Payer: Monida First Choice Health |
$0.97
|
| Rate for Payer: Monida Montana Health Co-op |
$0.95
|
| Rate for Payer: Monida PacificSource |
$0.95
|
|
|
ACE BANDAGE 3' W/VELCRO
|
Facility
|
OP
|
$1.00
|
|
|
Service Code
|
HCPCS A4590
|
| Hospital Charge Code |
2830020
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$0.70 |
| Max. Negotiated Rate |
$1.00 |
| Rate for Payer: Aetna Commercial |
$0.95
|
| Rate for Payer: Aetna Medicare |
$0.90
|
| Rate for Payer: BCBS MT CHIP |
$0.90
|
| Rate for Payer: BCBS MT Closed Plan Network |
$0.95
|
| Rate for Payer: BCBS MT HealthLink |
$0.90
|
| Rate for Payer: BCBS MT Medicare |
$0.90
|
| Rate for Payer: BCBS MT POS |
$0.95
|
| Rate for Payer: BCBS MT Traditional |
$1.00
|
| Rate for Payer: Cash Price |
$0.90
|
| Rate for Payer: Cigna Commercial |
$0.95
|
| Rate for Payer: Cigna Medicare |
$0.90
|
| Rate for Payer: Medicaid All Medicaid |
$0.92
|
| Rate for Payer: Medicare All Medicare |
$0.70
|
| Rate for Payer: Monida Allegiance |
$0.95
|
| Rate for Payer: Monida First Choice Health |
$0.97
|
| Rate for Payer: Monida Montana Health Co-op |
$0.95
|
| Rate for Payer: Monida PacificSource |
$0.95
|
|
|
ACE BANDAGE 4' W/VELCRO
|
Facility
|
OP
|
$1.00
|
|
|
Service Code
|
HCPCS A4590
|
| Hospital Charge Code |
2830018
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$0.70 |
| Max. Negotiated Rate |
$1.00 |
| Rate for Payer: Aetna Commercial |
$0.95
|
| Rate for Payer: Aetna Medicare |
$0.90
|
| Rate for Payer: BCBS MT CHIP |
$0.90
|
| Rate for Payer: BCBS MT Closed Plan Network |
$0.95
|
| Rate for Payer: BCBS MT HealthLink |
$0.90
|
| Rate for Payer: BCBS MT Medicare |
$0.90
|
| Rate for Payer: BCBS MT POS |
$0.95
|
| Rate for Payer: BCBS MT Traditional |
$1.00
|
| Rate for Payer: Cash Price |
$0.90
|
| Rate for Payer: Cigna Commercial |
$0.95
|
| Rate for Payer: Cigna Medicare |
$0.90
|
| Rate for Payer: Medicaid All Medicaid |
$0.92
|
| Rate for Payer: Medicare All Medicare |
$0.70
|
| Rate for Payer: Monida Allegiance |
$0.95
|
| Rate for Payer: Monida First Choice Health |
$0.97
|
| Rate for Payer: Monida Montana Health Co-op |
$0.95
|
| Rate for Payer: Monida PacificSource |
$0.95
|
|
|
ACE BANDAGE 4' W/VELCRO
|
Facility
|
IP
|
$1.00
|
|
|
Service Code
|
HCPCS A4590
|
| Hospital Charge Code |
2830018
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$0.70 |
| Max. Negotiated Rate |
$1.00 |
| Rate for Payer: Aetna Commercial |
$0.95
|
| Rate for Payer: Aetna Medicare |
$0.90
|
| Rate for Payer: BCBS MT CHIP |
$0.90
|
| Rate for Payer: BCBS MT Closed Plan Network |
$0.95
|
| Rate for Payer: BCBS MT HealthLink |
$0.90
|
| Rate for Payer: BCBS MT Medicare |
$0.90
|
| Rate for Payer: BCBS MT POS |
$0.95
|
| Rate for Payer: BCBS MT Traditional |
$1.00
|
| Rate for Payer: Cash Price |
$0.90
|
| Rate for Payer: Cigna Commercial |
$0.95
|
| Rate for Payer: Cigna Medicare |
$0.90
|
| Rate for Payer: Medicaid All Medicaid |
$0.92
|
| Rate for Payer: Medicare All Medicare |
$0.70
|
| Rate for Payer: Monida Allegiance |
$0.95
|
| Rate for Payer: Monida First Choice Health |
$0.97
|
| Rate for Payer: Monida Montana Health Co-op |
$0.95
|
| Rate for Payer: Monida PacificSource |
$0.95
|
|
|
ACE BANDAGE 6'' W/ VELCRO
|
Facility
|
OP
|
$6.00
|
|
|
Service Code
|
HCPCS A4590
|
| Hospital Charge Code |
2830449
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$4.20 |
| Max. Negotiated Rate |
$6.00 |
| Rate for Payer: Aetna Commercial |
$5.70
|
| Rate for Payer: Aetna Medicare |
$5.40
|
| Rate for Payer: BCBS MT CHIP |
$5.40
|
| Rate for Payer: BCBS MT Closed Plan Network |
$5.70
|
| Rate for Payer: BCBS MT HealthLink |
$5.40
|
| Rate for Payer: BCBS MT Medicare |
$5.40
|
| Rate for Payer: BCBS MT POS |
$5.70
|
| Rate for Payer: BCBS MT Traditional |
$6.00
|
| Rate for Payer: Cash Price |
$5.40
|
| Rate for Payer: Cigna Commercial |
$5.70
|
| Rate for Payer: Cigna Medicare |
$5.40
|
| Rate for Payer: Medicaid All Medicaid |
$5.52
|
| Rate for Payer: Medicare All Medicare |
$4.20
|
| Rate for Payer: Monida Allegiance |
$5.70
|
| Rate for Payer: Monida First Choice Health |
$5.82
|
| Rate for Payer: Monida Montana Health Co-op |
$5.70
|
| Rate for Payer: Monida PacificSource |
$5.70
|
|
|
ACE BANDAGE 6'' W/ VELCRO
|
Facility
|
IP
|
$6.00
|
|
|
Service Code
|
HCPCS A4590
|
| Hospital Charge Code |
2830449
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$4.20 |
| Max. Negotiated Rate |
$6.00 |
| Rate for Payer: Aetna Commercial |
$5.70
|
| Rate for Payer: Aetna Medicare |
$5.40
|
| Rate for Payer: BCBS MT CHIP |
$5.40
|
| Rate for Payer: BCBS MT Closed Plan Network |
$5.70
|
| Rate for Payer: BCBS MT HealthLink |
$5.40
|
| Rate for Payer: BCBS MT Medicare |
$5.40
|
| Rate for Payer: BCBS MT POS |
$5.70
|
| Rate for Payer: BCBS MT Traditional |
$6.00
|
| Rate for Payer: Cash Price |
$5.40
|
| Rate for Payer: Cigna Commercial |
$5.70
|
| Rate for Payer: Cigna Medicare |
$5.40
|
| Rate for Payer: Medicaid All Medicaid |
$5.52
|
| Rate for Payer: Medicare All Medicare |
$4.20
|
| Rate for Payer: Monida Allegiance |
$5.70
|
| Rate for Payer: Monida First Choice Health |
$5.82
|
| Rate for Payer: Monida Montana Health Co-op |
$5.70
|
| Rate for Payer: Monida PacificSource |
$5.70
|
|
|
ACETAMINOPHEN
|
Facility
|
IP
|
$174.00
|
|
|
Service Code
|
CPT 80143
|
| Hospital Charge Code |
4080307
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$121.80 |
| Max. Negotiated Rate |
$174.00 |
| Rate for Payer: Aetna Commercial |
$165.30
|
| Rate for Payer: Aetna Medicare |
$156.60
|
| Rate for Payer: BCBS MT CHIP |
$156.60
|
| Rate for Payer: BCBS MT Closed Plan Network |
$165.30
|
| Rate for Payer: BCBS MT HealthLink |
$156.60
|
| Rate for Payer: BCBS MT Medicare |
$156.60
|
| Rate for Payer: BCBS MT POS |
$165.30
|
| Rate for Payer: BCBS MT Traditional |
$174.00
|
| Rate for Payer: Cash Price |
$156.60
|
| Rate for Payer: Cigna Commercial |
$165.30
|
| Rate for Payer: Cigna Medicare |
$156.60
|
| Rate for Payer: Medicaid All Medicaid |
$160.08
|
| Rate for Payer: Medicare All Medicare |
$121.80
|
| Rate for Payer: Monida Allegiance |
$165.30
|
| Rate for Payer: Monida First Choice Health |
$168.78
|
| Rate for Payer: Monida Montana Health Co-op |
$165.30
|
| Rate for Payer: Monida PacificSource |
$165.30
|
|
|
ACETAMINOPHEN
|
Facility
|
OP
|
$174.00
|
|
|
Service Code
|
CPT 80143
|
| Hospital Charge Code |
4080307
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$121.80 |
| Max. Negotiated Rate |
$174.00 |
| Rate for Payer: Aetna Commercial |
$165.30
|
| Rate for Payer: Aetna Medicare |
$156.60
|
| Rate for Payer: BCBS MT CHIP |
$156.60
|
| Rate for Payer: BCBS MT Closed Plan Network |
$165.30
|
| Rate for Payer: BCBS MT HealthLink |
$156.60
|
| Rate for Payer: BCBS MT Medicare |
$156.60
|
| Rate for Payer: BCBS MT POS |
$165.30
|
| Rate for Payer: BCBS MT Traditional |
$174.00
|
| Rate for Payer: Cash Price |
$156.60
|
| Rate for Payer: Cigna Commercial |
$165.30
|
| Rate for Payer: Cigna Medicare |
$156.60
|
| Rate for Payer: Medicaid All Medicaid |
$160.08
|
| Rate for Payer: Medicare All Medicare |
$121.80
|
| Rate for Payer: Monida Allegiance |
$165.30
|
| Rate for Payer: Monida First Choice Health |
$168.78
|
| Rate for Payer: Monida Montana Health Co-op |
$165.30
|
| Rate for Payer: Monida PacificSource |
$165.30
|
|
|
ACETAMINOPHEN [160 MG/5 ML] 5ML CUP
|
Facility
|
IP
|
$7.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
3000005
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.90 |
| Max. Negotiated Rate |
$7.00 |
| Rate for Payer: Aetna Commercial |
$6.65
|
| Rate for Payer: Aetna Medicare |
$6.30
|
| Rate for Payer: BCBS MT CHIP |
$6.30
|
| Rate for Payer: BCBS MT Closed Plan Network |
$6.65
|
| Rate for Payer: BCBS MT HealthLink |
$6.30
|
| Rate for Payer: BCBS MT Medicare |
$6.30
|
| Rate for Payer: BCBS MT POS |
$6.65
|
| Rate for Payer: BCBS MT Traditional |
$7.00
|
| Rate for Payer: Cash Price |
$6.30
|
| Rate for Payer: Cigna Commercial |
$6.65
|
| Rate for Payer: Cigna Medicare |
$6.30
|
| Rate for Payer: Medicaid All Medicaid |
$6.44
|
| Rate for Payer: Medicare All Medicare |
$4.90
|
| Rate for Payer: Monida Allegiance |
$6.65
|
| Rate for Payer: Monida First Choice Health |
$6.79
|
| Rate for Payer: Monida Montana Health Co-op |
$6.65
|
| Rate for Payer: Monida PacificSource |
$6.65
|
|
|
ACETAMINOPHEN [160 MG/5 ML] 5ML CUP
|
Facility
|
OP
|
$7.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
3000005
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.90 |
| Max. Negotiated Rate |
$7.00 |
| Rate for Payer: Aetna Commercial |
$6.65
|
| Rate for Payer: Aetna Medicare |
$6.30
|
| Rate for Payer: BCBS MT CHIP |
$6.30
|
| Rate for Payer: BCBS MT Closed Plan Network |
$6.65
|
| Rate for Payer: BCBS MT HealthLink |
$6.30
|
| Rate for Payer: BCBS MT Medicare |
$6.30
|
| Rate for Payer: BCBS MT POS |
$6.65
|
| Rate for Payer: BCBS MT Traditional |
$7.00
|
| Rate for Payer: Cash Price |
$6.30
|
| Rate for Payer: Cigna Commercial |
$6.65
|
| Rate for Payer: Cigna Medicare |
$6.30
|
| Rate for Payer: Medicaid All Medicaid |
$6.44
|
| Rate for Payer: Medicare All Medicare |
$4.90
|
| Rate for Payer: Monida Allegiance |
$6.65
|
| Rate for Payer: Monida First Choice Health |
$6.79
|
| Rate for Payer: Monida Montana Health Co-op |
$6.65
|
| Rate for Payer: Monida PacificSource |
$6.65
|
|
