|
TENNIS ELBOW SUPPORT LG
|
Facility
|
IP
|
$27.00
|
|
| Hospital Charge Code |
2893610
|
|
Hospital Revenue Code
|
290
|
| 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
|
|
|
TENNIS ELBOW SUPPORT MD
|
Facility
|
IP
|
$40.00
|
|
| Hospital Charge Code |
2893609
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$28.00 |
| Max. Negotiated Rate |
$40.00 |
| Rate for Payer: Aetna Commercial |
$38.00
|
| Rate for Payer: Aetna Medicare |
$36.00
|
| Rate for Payer: BCBS MT CHIP |
$36.00
|
| Rate for Payer: BCBS MT Closed Plan Network |
$38.00
|
| Rate for Payer: BCBS MT HealthLink |
$36.00
|
| Rate for Payer: BCBS MT Medicare |
$36.00
|
| Rate for Payer: BCBS MT POS |
$38.00
|
| Rate for Payer: BCBS MT Traditional |
$40.00
|
| Rate for Payer: Cash Price |
$36.00
|
| Rate for Payer: Cigna Commercial |
$38.00
|
| Rate for Payer: Cigna Medicare |
$36.00
|
| Rate for Payer: Medicaid All Medicaid |
$36.80
|
| Rate for Payer: Medicare All Medicare |
$28.00
|
| Rate for Payer: Monida Allegiance |
$38.00
|
| Rate for Payer: Monida First Choice Health |
$38.80
|
| Rate for Payer: Monida Montana Health Co-op |
$38.00
|
| Rate for Payer: Monida PacificSource |
$38.00
|
|
|
TENNIS ELBOW SUPPORT MD
|
Facility
|
OP
|
$40.00
|
|
| Hospital Charge Code |
2893609
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$28.00 |
| Max. Negotiated Rate |
$40.00 |
| Rate for Payer: Aetna Commercial |
$38.00
|
| Rate for Payer: Aetna Medicare |
$36.00
|
| Rate for Payer: BCBS MT CHIP |
$36.00
|
| Rate for Payer: BCBS MT Closed Plan Network |
$38.00
|
| Rate for Payer: BCBS MT HealthLink |
$36.00
|
| Rate for Payer: BCBS MT Medicare |
$36.00
|
| Rate for Payer: BCBS MT POS |
$38.00
|
| Rate for Payer: BCBS MT Traditional |
$40.00
|
| Rate for Payer: Cash Price |
$36.00
|
| Rate for Payer: Cigna Commercial |
$38.00
|
| Rate for Payer: Cigna Medicare |
$36.00
|
| Rate for Payer: Medicaid All Medicaid |
$36.80
|
| Rate for Payer: Medicare All Medicare |
$28.00
|
| Rate for Payer: Monida Allegiance |
$38.00
|
| Rate for Payer: Monida First Choice Health |
$38.80
|
| Rate for Payer: Monida Montana Health Co-op |
$38.00
|
| Rate for Payer: Monida PacificSource |
$38.00
|
|
|
TENNIS ELBOW SUPPORT SM
|
Facility
|
OP
|
$45.00
|
|
|
Service Code
|
HCPCS A4570
|
| Hospital Charge Code |
2840104
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$31.50 |
| Max. Negotiated Rate |
$45.00 |
| Rate for Payer: Aetna Commercial |
$42.75
|
| Rate for Payer: Aetna Medicare |
$40.50
|
| Rate for Payer: BCBS MT CHIP |
$40.50
|
| Rate for Payer: BCBS MT Closed Plan Network |
$42.75
|
| Rate for Payer: BCBS MT HealthLink |
$40.50
|
| Rate for Payer: BCBS MT Medicare |
$40.50
|
| Rate for Payer: BCBS MT POS |
$42.75
|
| Rate for Payer: BCBS MT Traditional |
$45.00
|
| Rate for Payer: Cash Price |
$40.50
|
| Rate for Payer: Cigna Commercial |
$42.75
|
| Rate for Payer: Cigna Medicare |
$40.50
|
| Rate for Payer: Medicaid All Medicaid |
$41.40
|
| Rate for Payer: Medicare All Medicare |
$31.50
|
| Rate for Payer: Monida Allegiance |
$42.75
|
| Rate for Payer: Monida First Choice Health |
$43.65
|
| Rate for Payer: Monida Montana Health Co-op |
$42.75
|
| Rate for Payer: Monida PacificSource |
$42.75
|
|
|
TENNIS ELBOW SUPPORT SM
|
Facility
|
IP
|
$45.00
|
|
|
Service Code
|
HCPCS A4570
|
| Hospital Charge Code |
2840104
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$31.50 |
| Max. Negotiated Rate |
$45.00 |
| Rate for Payer: Aetna Commercial |
$42.75
|
| Rate for Payer: Aetna Medicare |
$40.50
|
| Rate for Payer: BCBS MT CHIP |
$40.50
|
| Rate for Payer: BCBS MT Closed Plan Network |
$42.75
|
| Rate for Payer: BCBS MT HealthLink |
$40.50
|
| Rate for Payer: BCBS MT Medicare |
$40.50
|
| Rate for Payer: BCBS MT POS |
$42.75
|
| Rate for Payer: BCBS MT Traditional |
$45.00
|
| Rate for Payer: Cash Price |
$40.50
|
| Rate for Payer: Cigna Commercial |
$42.75
|
| Rate for Payer: Cigna Medicare |
$40.50
|
| Rate for Payer: Medicaid All Medicaid |
$41.40
|
| Rate for Payer: Medicare All Medicare |
$31.50
|
| Rate for Payer: Monida Allegiance |
$42.75
|
| Rate for Payer: Monida First Choice Health |
$43.65
|
| Rate for Payer: Monida Montana Health Co-op |
$42.75
|
| Rate for Payer: Monida PacificSource |
$42.75
|
|
|
TENNIS ELBOW SUPPORT XLG
|
Facility
|
OP
|
$40.00
|
|
| Hospital Charge Code |
2893611
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$28.00 |
| Max. Negotiated Rate |
$40.00 |
| Rate for Payer: Aetna Commercial |
$38.00
|
| Rate for Payer: Aetna Medicare |
$36.00
|
| Rate for Payer: BCBS MT CHIP |
$36.00
|
| Rate for Payer: BCBS MT Closed Plan Network |
$38.00
|
| Rate for Payer: BCBS MT HealthLink |
$36.00
|
| Rate for Payer: BCBS MT Medicare |
$36.00
|
| Rate for Payer: BCBS MT POS |
$38.00
|
| Rate for Payer: BCBS MT Traditional |
$40.00
|
| Rate for Payer: Cash Price |
$36.00
|
| Rate for Payer: Cigna Commercial |
$38.00
|
| Rate for Payer: Cigna Medicare |
$36.00
|
| Rate for Payer: Medicaid All Medicaid |
$36.80
|
| Rate for Payer: Medicare All Medicare |
$28.00
|
| Rate for Payer: Monida Allegiance |
$38.00
|
| Rate for Payer: Monida First Choice Health |
$38.80
|
| Rate for Payer: Monida Montana Health Co-op |
$38.00
|
| Rate for Payer: Monida PacificSource |
$38.00
|
|
|
TENNIS ELBOW SUPPORT XLG
|
Facility
|
IP
|
$40.00
|
|
| Hospital Charge Code |
2893611
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$28.00 |
| Max. Negotiated Rate |
$40.00 |
| Rate for Payer: Aetna Commercial |
$38.00
|
| Rate for Payer: Aetna Medicare |
$36.00
|
| Rate for Payer: BCBS MT CHIP |
$36.00
|
| Rate for Payer: BCBS MT Closed Plan Network |
$38.00
|
| Rate for Payer: BCBS MT HealthLink |
$36.00
|
| Rate for Payer: BCBS MT Medicare |
$36.00
|
| Rate for Payer: BCBS MT POS |
$38.00
|
| Rate for Payer: BCBS MT Traditional |
$40.00
|
| Rate for Payer: Cash Price |
$36.00
|
| Rate for Payer: Cigna Commercial |
$38.00
|
| Rate for Payer: Cigna Medicare |
$36.00
|
| Rate for Payer: Medicaid All Medicaid |
$36.80
|
| Rate for Payer: Medicare All Medicare |
$28.00
|
| Rate for Payer: Monida Allegiance |
$38.00
|
| Rate for Payer: Monida First Choice Health |
$38.80
|
| Rate for Payer: Monida Montana Health Co-op |
$38.00
|
| Rate for Payer: Monida PacificSource |
$38.00
|
|
|
TERAZOSIN CAP [1 MG] NF
|
Facility
|
OP
|
$8.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
3000444
|
|
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
|
|
|
TERAZOSIN CAP [1 MG] NF
|
Facility
|
IP
|
$8.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
3000444
|
|
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
|
|
|
TERAZOSIN TAB [5 MG]
|
Facility
|
IP
|
$8.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
3000445
|
|
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
|
|
|
TERAZOSIN TAB [5 MG]
|
Facility
|
OP
|
$8.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
3000445
|
|
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
|
|
|
TERBINAFINE TAB [250 MG] NF
|
Facility
|
IP
|
$41.00
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
3007524
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$28.70 |
| Max. Negotiated Rate |
$41.00 |
| Rate for Payer: Aetna Commercial |
$38.95
|
| Rate for Payer: Aetna Medicare |
$36.90
|
| Rate for Payer: BCBS MT CHIP |
$36.90
|
| Rate for Payer: BCBS MT Closed Plan Network |
$38.95
|
| Rate for Payer: BCBS MT HealthLink |
$36.90
|
| Rate for Payer: BCBS MT Medicare |
$36.90
|
| Rate for Payer: BCBS MT POS |
$38.95
|
| Rate for Payer: BCBS MT Traditional |
$41.00
|
| Rate for Payer: Cash Price |
$36.90
|
| Rate for Payer: Cigna Commercial |
$38.95
|
| Rate for Payer: Cigna Medicare |
$36.90
|
| Rate for Payer: Medicaid All Medicaid |
$37.72
|
| Rate for Payer: Medicare All Medicare |
$28.70
|
| Rate for Payer: Monida Allegiance |
$38.95
|
| Rate for Payer: Monida First Choice Health |
$39.77
|
| Rate for Payer: Monida Montana Health Co-op |
$38.95
|
| Rate for Payer: Monida PacificSource |
$38.95
|
|
|
TERBINAFINE TAB [250 MG] NF
|
Facility
|
OP
|
$41.00
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
3007524
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$28.70 |
| Max. Negotiated Rate |
$41.00 |
| Rate for Payer: Aetna Commercial |
$38.95
|
| Rate for Payer: Aetna Medicare |
$36.90
|
| Rate for Payer: BCBS MT CHIP |
$36.90
|
| Rate for Payer: BCBS MT Closed Plan Network |
$38.95
|
| Rate for Payer: BCBS MT HealthLink |
$36.90
|
| Rate for Payer: BCBS MT Medicare |
$36.90
|
| Rate for Payer: BCBS MT POS |
$38.95
|
| Rate for Payer: BCBS MT Traditional |
$41.00
|
| Rate for Payer: Cash Price |
$36.90
|
| Rate for Payer: Cigna Commercial |
$38.95
|
| Rate for Payer: Cigna Medicare |
$36.90
|
| Rate for Payer: Medicaid All Medicaid |
$37.72
|
| Rate for Payer: Medicare All Medicare |
$28.70
|
| Rate for Payer: Monida Allegiance |
$38.95
|
| Rate for Payer: Monida First Choice Health |
$39.77
|
| Rate for Payer: Monida Montana Health Co-op |
$38.95
|
| Rate for Payer: Monida PacificSource |
$38.95
|
|
|
TERBUTALINE SUBQ [1 MG/ML]
|
Facility
|
IP
|
$8.00
|
|
|
Service Code
|
HCPCS J3105
|
| Hospital Charge Code |
3000446
|
|
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
|
|
|
TERBUTALINE SUBQ [1 MG/ML]
|
Facility
|
OP
|
$8.00
|
|
|
Service Code
|
HCPCS J3105
|
| Hospital Charge Code |
3000446
|
|
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
|
|
|
TESTOSTERONE, FREE (144980)
|
Facility
|
OP
|
$16.00
|
|
|
Service Code
|
HCPCS 84402
|
| Hospital Charge Code |
4084402
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$11.20 |
| Max. Negotiated Rate |
$16.00 |
| Rate for Payer: Aetna Commercial |
$15.20
|
| Rate for Payer: Aetna Medicare |
$14.40
|
| Rate for Payer: BCBS MT CHIP |
$14.40
|
| Rate for Payer: BCBS MT Closed Plan Network |
$15.20
|
| Rate for Payer: BCBS MT HealthLink |
$14.40
|
| Rate for Payer: BCBS MT Medicare |
$14.40
|
| Rate for Payer: BCBS MT POS |
$15.20
|
| Rate for Payer: BCBS MT Traditional |
$16.00
|
| Rate for Payer: Cash Price |
$14.40
|
| Rate for Payer: Cigna Commercial |
$15.20
|
| Rate for Payer: Cigna Medicare |
$14.40
|
| Rate for Payer: Medicaid All Medicaid |
$14.72
|
| Rate for Payer: Medicare All Medicare |
$11.20
|
| Rate for Payer: Monida Allegiance |
$15.20
|
| Rate for Payer: Monida First Choice Health |
$15.52
|
| Rate for Payer: Monida Montana Health Co-op |
$15.20
|
| Rate for Payer: Monida PacificSource |
$15.20
|
|
|
TESTOSTERONE, FREE (144980)
|
Facility
|
IP
|
$16.00
|
|
|
Service Code
|
HCPCS 84402
|
| Hospital Charge Code |
4084402
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$11.20 |
| Max. Negotiated Rate |
$16.00 |
| Rate for Payer: Aetna Commercial |
$15.20
|
| Rate for Payer: Aetna Medicare |
$14.40
|
| Rate for Payer: BCBS MT CHIP |
$14.40
|
| Rate for Payer: BCBS MT Closed Plan Network |
$15.20
|
| Rate for Payer: BCBS MT HealthLink |
$14.40
|
| Rate for Payer: BCBS MT Medicare |
$14.40
|
| Rate for Payer: BCBS MT POS |
$15.20
|
| Rate for Payer: BCBS MT Traditional |
$16.00
|
| Rate for Payer: Cash Price |
$14.40
|
| Rate for Payer: Cigna Commercial |
$15.20
|
| Rate for Payer: Cigna Medicare |
$14.40
|
| Rate for Payer: Medicaid All Medicaid |
$14.72
|
| Rate for Payer: Medicare All Medicare |
$11.20
|
| Rate for Payer: Monida Allegiance |
$15.20
|
| Rate for Payer: Monida First Choice Health |
$15.52
|
| Rate for Payer: Monida Montana Health Co-op |
$15.20
|
| Rate for Payer: Monida PacificSource |
$15.20
|
|
|
TESTOSTERONE, TOTAL (004226)
|
Facility
|
OP
|
$88.00
|
|
|
Service Code
|
HCPCS 84403
|
| Hospital Charge Code |
4084403
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$61.60 |
| Max. Negotiated Rate |
$88.00 |
| Rate for Payer: Aetna Commercial |
$83.60
|
| Rate for Payer: Aetna Medicare |
$79.20
|
| Rate for Payer: BCBS MT CHIP |
$79.20
|
| Rate for Payer: BCBS MT Closed Plan Network |
$83.60
|
| Rate for Payer: BCBS MT HealthLink |
$79.20
|
| Rate for Payer: BCBS MT Medicare |
$79.20
|
| Rate for Payer: BCBS MT POS |
$83.60
|
| Rate for Payer: BCBS MT Traditional |
$88.00
|
| Rate for Payer: Cash Price |
$79.20
|
| Rate for Payer: Cigna Commercial |
$83.60
|
| Rate for Payer: Cigna Medicare |
$79.20
|
| Rate for Payer: Medicaid All Medicaid |
$80.96
|
| Rate for Payer: Medicare All Medicare |
$61.60
|
| Rate for Payer: Monida Allegiance |
$83.60
|
| Rate for Payer: Monida First Choice Health |
$85.36
|
| Rate for Payer: Monida Montana Health Co-op |
$83.60
|
| Rate for Payer: Monida PacificSource |
$83.60
|
|
|
TESTOSTERONE, TOTAL (004226)
|
Facility
|
IP
|
$88.00
|
|
|
Service Code
|
HCPCS 84403
|
| Hospital Charge Code |
4084403
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$61.60 |
| Max. Negotiated Rate |
$88.00 |
| Rate for Payer: Aetna Commercial |
$83.60
|
| Rate for Payer: Aetna Medicare |
$79.20
|
| Rate for Payer: BCBS MT CHIP |
$79.20
|
| Rate for Payer: BCBS MT Closed Plan Network |
$83.60
|
| Rate for Payer: BCBS MT HealthLink |
$79.20
|
| Rate for Payer: BCBS MT Medicare |
$79.20
|
| Rate for Payer: BCBS MT POS |
$83.60
|
| Rate for Payer: BCBS MT Traditional |
$88.00
|
| Rate for Payer: Cash Price |
$79.20
|
| Rate for Payer: Cigna Commercial |
$83.60
|
| Rate for Payer: Cigna Medicare |
$79.20
|
| Rate for Payer: Medicaid All Medicaid |
$80.96
|
| Rate for Payer: Medicare All Medicare |
$61.60
|
| Rate for Payer: Monida Allegiance |
$83.60
|
| Rate for Payer: Monida First Choice Health |
$85.36
|
| Rate for Payer: Monida Montana Health Co-op |
$83.60
|
| Rate for Payer: Monida PacificSource |
$83.60
|
|
|
TESTOSTERONE TOTAL AND BIOAVAILABLE
|
Facility
|
OP
|
$120.00
|
|
|
Service Code
|
HCPCS 84410
|
| Hospital Charge Code |
4087960
|
|
Hospital Revenue Code
|
302
|
| 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
|
|
|
TESTOSTERONE TOTAL AND BIOAVAILABLE
|
Facility
|
IP
|
$120.00
|
|
|
Service Code
|
HCPCS 84410
|
| Hospital Charge Code |
4087960
|
|
Hospital Revenue Code
|
302
|
| 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
|
|
|
TETANUS IMMUNE GLOBULIN SYR. 250 UNITS
|
Facility
|
OP
|
$1,058.90
|
|
|
Service Code
|
HCPCS J1670
|
| Hospital Charge Code |
3007401
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$741.23 |
| Max. Negotiated Rate |
$1,058.90 |
| Rate for Payer: Aetna Commercial |
$1,005.96
|
| Rate for Payer: Aetna Medicare |
$953.01
|
| Rate for Payer: BCBS MT CHIP |
$953.01
|
| Rate for Payer: BCBS MT Closed Plan Network |
$1,005.96
|
| Rate for Payer: BCBS MT HealthLink |
$953.01
|
| Rate for Payer: BCBS MT Medicare |
$953.01
|
| Rate for Payer: BCBS MT POS |
$1,005.96
|
| Rate for Payer: BCBS MT Traditional |
$1,058.90
|
| Rate for Payer: Cash Price |
$953.01
|
| Rate for Payer: Cigna Commercial |
$1,005.96
|
| Rate for Payer: Cigna Medicare |
$953.01
|
| Rate for Payer: Medicaid All Medicaid |
$974.19
|
| Rate for Payer: Medicare All Medicare |
$741.23
|
| Rate for Payer: Monida Allegiance |
$1,005.96
|
| Rate for Payer: Monida First Choice Health |
$1,027.13
|
| Rate for Payer: Monida Montana Health Co-op |
$1,005.96
|
| Rate for Payer: Monida PacificSource |
$1,005.96
|
|
|
TETANUS IMMUNE GLOBULIN SYR. 250 UNITS
|
Facility
|
IP
|
$1,058.90
|
|
|
Service Code
|
HCPCS J1670
|
| Hospital Charge Code |
3007401
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$741.23 |
| Max. Negotiated Rate |
$1,058.90 |
| Rate for Payer: Aetna Commercial |
$1,005.96
|
| Rate for Payer: Aetna Medicare |
$953.01
|
| Rate for Payer: BCBS MT CHIP |
$953.01
|
| Rate for Payer: BCBS MT Closed Plan Network |
$1,005.96
|
| Rate for Payer: BCBS MT HealthLink |
$953.01
|
| Rate for Payer: BCBS MT Medicare |
$953.01
|
| Rate for Payer: BCBS MT POS |
$1,005.96
|
| Rate for Payer: BCBS MT Traditional |
$1,058.90
|
| Rate for Payer: Cash Price |
$953.01
|
| Rate for Payer: Cigna Commercial |
$1,005.96
|
| Rate for Payer: Cigna Medicare |
$953.01
|
| Rate for Payer: Medicaid All Medicaid |
$974.19
|
| Rate for Payer: Medicare All Medicare |
$741.23
|
| Rate for Payer: Monida Allegiance |
$1,005.96
|
| Rate for Payer: Monida First Choice Health |
$1,027.13
|
| Rate for Payer: Monida Montana Health Co-op |
$1,005.96
|
| Rate for Payer: Monida PacificSource |
$1,005.96
|
|
|
TETRACAINE OPTH [5 ML]
|
Facility
|
IP
|
$47.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
3000447
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$32.90 |
| Max. Negotiated Rate |
$47.00 |
| Rate for Payer: Aetna Commercial |
$44.65
|
| Rate for Payer: Aetna Medicare |
$42.30
|
| Rate for Payer: BCBS MT CHIP |
$42.30
|
| Rate for Payer: BCBS MT Closed Plan Network |
$44.65
|
| Rate for Payer: BCBS MT HealthLink |
$42.30
|
| Rate for Payer: BCBS MT Medicare |
$42.30
|
| Rate for Payer: BCBS MT POS |
$44.65
|
| Rate for Payer: BCBS MT Traditional |
$47.00
|
| Rate for Payer: Cash Price |
$42.30
|
| Rate for Payer: Cigna Commercial |
$44.65
|
| Rate for Payer: Cigna Medicare |
$42.30
|
| Rate for Payer: Medicaid All Medicaid |
$43.24
|
| Rate for Payer: Medicare All Medicare |
$32.90
|
| Rate for Payer: Monida Allegiance |
$44.65
|
| Rate for Payer: Monida First Choice Health |
$45.59
|
| Rate for Payer: Monida Montana Health Co-op |
$44.65
|
| Rate for Payer: Monida PacificSource |
$44.65
|
|
|
TETRACAINE OPTH [5 ML]
|
Facility
|
OP
|
$47.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
3000447
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$32.90 |
| Max. Negotiated Rate |
$47.00 |
| Rate for Payer: Aetna Commercial |
$44.65
|
| Rate for Payer: Aetna Medicare |
$42.30
|
| Rate for Payer: BCBS MT CHIP |
$42.30
|
| Rate for Payer: BCBS MT Closed Plan Network |
$44.65
|
| Rate for Payer: BCBS MT HealthLink |
$42.30
|
| Rate for Payer: BCBS MT Medicare |
$42.30
|
| Rate for Payer: BCBS MT POS |
$44.65
|
| Rate for Payer: BCBS MT Traditional |
$47.00
|
| Rate for Payer: Cash Price |
$42.30
|
| Rate for Payer: Cigna Commercial |
$44.65
|
| Rate for Payer: Cigna Medicare |
$42.30
|
| Rate for Payer: Medicaid All Medicaid |
$43.24
|
| Rate for Payer: Medicare All Medicare |
$32.90
|
| Rate for Payer: Monida Allegiance |
$44.65
|
| Rate for Payer: Monida First Choice Health |
$45.59
|
| Rate for Payer: Monida Montana Health Co-op |
$44.65
|
| Rate for Payer: Monida PacificSource |
$44.65
|
|
