|
CARBIDOPA/ LEVO TAB [25-100 MG]
|
Facility
|
OP
|
$8.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
3000069
|
|
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
|
|
|
CARBIDOPA/ LEVO TAB [25-100 MG]
|
Facility
|
IP
|
$8.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
3000069
|
|
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
|
|
|
CARBON DIOXIDE
|
Facility
|
OP
|
$50.00
|
|
|
Service Code
|
HCPCS 82374
|
| Hospital Charge Code |
4082374
|
|
Hospital Revenue Code
|
300
|
| 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
|
|
|
CARBON DIOXIDE
|
Facility
|
IP
|
$50.00
|
|
|
Service Code
|
HCPCS 82374
|
| Hospital Charge Code |
4082374
|
|
Hospital Revenue Code
|
300
|
| 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
|
|
|
CARBOPROST TROMETHAMINE 250MCG/ML
|
Facility
|
OP
|
$515.10
|
|
|
Service Code
|
NDC 81298501005
|
| Hospital Charge Code |
3007378
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$360.57 |
| Max. Negotiated Rate |
$515.10 |
| Rate for Payer: Aetna Commercial |
$489.35
|
| Rate for Payer: Aetna Medicare |
$463.59
|
| Rate for Payer: BCBS MT CHIP |
$463.59
|
| Rate for Payer: BCBS MT Closed Plan Network |
$489.35
|
| Rate for Payer: BCBS MT HealthLink |
$463.59
|
| Rate for Payer: BCBS MT Medicare |
$463.59
|
| Rate for Payer: BCBS MT POS |
$489.35
|
| Rate for Payer: BCBS MT Traditional |
$515.10
|
| Rate for Payer: Cash Price |
$463.59
|
| Rate for Payer: Cigna Commercial |
$489.35
|
| Rate for Payer: Cigna Medicare |
$463.59
|
| Rate for Payer: Medicaid All Medicaid |
$473.89
|
| Rate for Payer: Medicare All Medicare |
$360.57
|
| Rate for Payer: Monida Allegiance |
$489.35
|
| Rate for Payer: Monida First Choice Health |
$499.65
|
| Rate for Payer: Monida Montana Health Co-op |
$489.35
|
| Rate for Payer: Monida PacificSource |
$489.35
|
|
|
CARBOPROST TROMETHAMINE 250MCG/ML
|
Facility
|
IP
|
$515.10
|
|
|
Service Code
|
NDC 81298501005
|
| Hospital Charge Code |
3007378
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$360.57 |
| Max. Negotiated Rate |
$515.10 |
| Rate for Payer: Aetna Commercial |
$489.35
|
| Rate for Payer: Aetna Medicare |
$463.59
|
| Rate for Payer: BCBS MT CHIP |
$463.59
|
| Rate for Payer: BCBS MT Closed Plan Network |
$489.35
|
| Rate for Payer: BCBS MT HealthLink |
$463.59
|
| Rate for Payer: BCBS MT Medicare |
$463.59
|
| Rate for Payer: BCBS MT POS |
$489.35
|
| Rate for Payer: BCBS MT Traditional |
$515.10
|
| Rate for Payer: Cash Price |
$463.59
|
| Rate for Payer: Cigna Commercial |
$489.35
|
| Rate for Payer: Cigna Medicare |
$463.59
|
| Rate for Payer: Medicaid All Medicaid |
$473.89
|
| Rate for Payer: Medicare All Medicare |
$360.57
|
| Rate for Payer: Monida Allegiance |
$489.35
|
| Rate for Payer: Monida First Choice Health |
$499.65
|
| Rate for Payer: Monida Montana Health Co-op |
$489.35
|
| Rate for Payer: Monida PacificSource |
$489.35
|
|
|
CARBOPROST TROMETHAMINE 250 MCG SDV
|
Facility
|
IP
|
$515.10
|
|
|
Service Code
|
NDC 81298501005
|
| Hospital Charge Code |
3007341
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$360.57 |
| Max. Negotiated Rate |
$515.10 |
| Rate for Payer: Aetna Commercial |
$489.35
|
| Rate for Payer: Aetna Medicare |
$463.59
|
| Rate for Payer: BCBS MT CHIP |
$463.59
|
| Rate for Payer: BCBS MT Closed Plan Network |
$489.35
|
| Rate for Payer: BCBS MT HealthLink |
$463.59
|
| Rate for Payer: BCBS MT Medicare |
$463.59
|
| Rate for Payer: BCBS MT POS |
$489.35
|
| Rate for Payer: BCBS MT Traditional |
$515.10
|
| Rate for Payer: Cash Price |
$463.59
|
| Rate for Payer: Cigna Commercial |
$489.35
|
| Rate for Payer: Cigna Medicare |
$463.59
|
| Rate for Payer: Medicaid All Medicaid |
$473.89
|
| Rate for Payer: Medicare All Medicare |
$360.57
|
| Rate for Payer: Monida Allegiance |
$489.35
|
| Rate for Payer: Monida First Choice Health |
$499.65
|
| Rate for Payer: Monida Montana Health Co-op |
$489.35
|
| Rate for Payer: Monida PacificSource |
$489.35
|
|
|
CARBOPROST TROMETHAMINE 250 MCG SDV
|
Facility
|
OP
|
$515.10
|
|
|
Service Code
|
NDC 81298501005
|
| Hospital Charge Code |
3007341
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$360.57 |
| Max. Negotiated Rate |
$515.10 |
| Rate for Payer: Aetna Commercial |
$489.35
|
| Rate for Payer: Aetna Medicare |
$463.59
|
| Rate for Payer: BCBS MT CHIP |
$463.59
|
| Rate for Payer: BCBS MT Closed Plan Network |
$489.35
|
| Rate for Payer: BCBS MT HealthLink |
$463.59
|
| Rate for Payer: BCBS MT Medicare |
$463.59
|
| Rate for Payer: BCBS MT POS |
$489.35
|
| Rate for Payer: BCBS MT Traditional |
$515.10
|
| Rate for Payer: Cash Price |
$463.59
|
| Rate for Payer: Cigna Commercial |
$489.35
|
| Rate for Payer: Cigna Medicare |
$463.59
|
| Rate for Payer: Medicaid All Medicaid |
$473.89
|
| Rate for Payer: Medicare All Medicare |
$360.57
|
| Rate for Payer: Monida Allegiance |
$489.35
|
| Rate for Payer: Monida First Choice Health |
$499.65
|
| Rate for Payer: Monida Montana Health Co-op |
$489.35
|
| Rate for Payer: Monida PacificSource |
$489.35
|
|
|
CARCINOEMBRYONIC ANTIGEN (002139)
|
Facility
|
OP
|
$78.00
|
|
|
Service Code
|
HCPCS 82378
|
| Hospital Charge Code |
4082378
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$54.60 |
| Max. Negotiated Rate |
$78.00 |
| Rate for Payer: Aetna Commercial |
$74.10
|
| Rate for Payer: Aetna Medicare |
$70.20
|
| Rate for Payer: BCBS MT CHIP |
$70.20
|
| Rate for Payer: BCBS MT Closed Plan Network |
$74.10
|
| Rate for Payer: BCBS MT HealthLink |
$70.20
|
| Rate for Payer: BCBS MT Medicare |
$70.20
|
| Rate for Payer: BCBS MT POS |
$74.10
|
| Rate for Payer: BCBS MT Traditional |
$78.00
|
| Rate for Payer: Cash Price |
$70.20
|
| Rate for Payer: Cigna Commercial |
$74.10
|
| Rate for Payer: Cigna Medicare |
$70.20
|
| Rate for Payer: Medicaid All Medicaid |
$71.76
|
| Rate for Payer: Medicare All Medicare |
$54.60
|
| Rate for Payer: Monida Allegiance |
$74.10
|
| Rate for Payer: Monida First Choice Health |
$75.66
|
| Rate for Payer: Monida Montana Health Co-op |
$74.10
|
| Rate for Payer: Monida PacificSource |
$74.10
|
|
|
CARCINOEMBRYONIC ANTIGEN (002139)
|
Facility
|
IP
|
$78.00
|
|
|
Service Code
|
HCPCS 82378
|
| Hospital Charge Code |
4082378
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$54.60 |
| Max. Negotiated Rate |
$78.00 |
| Rate for Payer: Aetna Commercial |
$74.10
|
| Rate for Payer: Aetna Medicare |
$70.20
|
| Rate for Payer: BCBS MT CHIP |
$70.20
|
| Rate for Payer: BCBS MT Closed Plan Network |
$74.10
|
| Rate for Payer: BCBS MT HealthLink |
$70.20
|
| Rate for Payer: BCBS MT Medicare |
$70.20
|
| Rate for Payer: BCBS MT POS |
$74.10
|
| Rate for Payer: BCBS MT Traditional |
$78.00
|
| Rate for Payer: Cash Price |
$70.20
|
| Rate for Payer: Cigna Commercial |
$74.10
|
| Rate for Payer: Cigna Medicare |
$70.20
|
| Rate for Payer: Medicaid All Medicaid |
$71.76
|
| Rate for Payer: Medicare All Medicare |
$54.60
|
| Rate for Payer: Monida Allegiance |
$74.10
|
| Rate for Payer: Monida First Choice Health |
$75.66
|
| Rate for Payer: Monida Montana Health Co-op |
$74.10
|
| Rate for Payer: Monida PacificSource |
$74.10
|
|
|
CARDIAC ARREST TREAT AT SCENE AMBULANCE
|
Facility
|
IP
|
$890.00
|
|
|
Service Code
|
HCPCS A0999 QN
|
| Hospital Charge Code |
600999
|
|
Hospital Revenue Code
|
540
|
| Min. Negotiated Rate |
$623.00 |
| Max. Negotiated Rate |
$890.00 |
| Rate for Payer: Aetna Commercial |
$845.50
|
| Rate for Payer: Aetna Medicare |
$801.00
|
| Rate for Payer: BCBS MT CHIP |
$801.00
|
| Rate for Payer: BCBS MT Closed Plan Network |
$845.50
|
| Rate for Payer: BCBS MT HealthLink |
$801.00
|
| Rate for Payer: BCBS MT Medicare |
$801.00
|
| Rate for Payer: BCBS MT POS |
$845.50
|
| Rate for Payer: BCBS MT Traditional |
$890.00
|
| Rate for Payer: Cash Price |
$801.00
|
| Rate for Payer: Cigna Commercial |
$845.50
|
| Rate for Payer: Cigna Medicare |
$801.00
|
| Rate for Payer: Medicaid All Medicaid |
$818.80
|
| Rate for Payer: Medicare All Medicare |
$623.00
|
| Rate for Payer: Monida Allegiance |
$845.50
|
| Rate for Payer: Monida First Choice Health |
$863.30
|
| Rate for Payer: Monida Montana Health Co-op |
$845.50
|
| Rate for Payer: Monida PacificSource |
$845.50
|
|
|
CARDIAC ARREST TREAT AT SCENE AMBULANCE
|
Facility
|
OP
|
$890.00
|
|
|
Service Code
|
HCPCS A0999 QN
|
| Hospital Charge Code |
600999
|
|
Hospital Revenue Code
|
540
|
| Min. Negotiated Rate |
$623.00 |
| Max. Negotiated Rate |
$890.00 |
| Rate for Payer: Aetna Commercial |
$845.50
|
| Rate for Payer: Aetna Medicare |
$801.00
|
| Rate for Payer: BCBS MT CHIP |
$801.00
|
| Rate for Payer: BCBS MT Closed Plan Network |
$845.50
|
| Rate for Payer: BCBS MT HealthLink |
$801.00
|
| Rate for Payer: BCBS MT Medicare |
$801.00
|
| Rate for Payer: BCBS MT POS |
$845.50
|
| Rate for Payer: BCBS MT Traditional |
$890.00
|
| Rate for Payer: Cash Price |
$801.00
|
| Rate for Payer: Cigna Commercial |
$845.50
|
| Rate for Payer: Cigna Medicare |
$801.00
|
| Rate for Payer: Medicaid All Medicaid |
$818.80
|
| Rate for Payer: Medicare All Medicare |
$623.00
|
| Rate for Payer: Monida Allegiance |
$845.50
|
| Rate for Payer: Monida First Choice Health |
$863.30
|
| Rate for Payer: Monida Montana Health Co-op |
$845.50
|
| Rate for Payer: Monida PacificSource |
$845.50
|
|
|
CARDIAC TROPONINS CONTROL LEV
|
Facility
|
OP
|
$182.43
|
|
| Hospital Charge Code |
90196530
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$127.70 |
| Max. Negotiated Rate |
$182.43 |
| Rate for Payer: Aetna Commercial |
$173.31
|
| Rate for Payer: Aetna Medicare |
$164.19
|
| Rate for Payer: BCBS MT CHIP |
$164.19
|
| Rate for Payer: BCBS MT Closed Plan Network |
$173.31
|
| Rate for Payer: BCBS MT HealthLink |
$164.19
|
| Rate for Payer: BCBS MT Medicare |
$164.19
|
| Rate for Payer: BCBS MT POS |
$173.31
|
| Rate for Payer: BCBS MT Traditional |
$182.43
|
| Rate for Payer: Cash Price |
$164.19
|
| Rate for Payer: Cigna Commercial |
$173.31
|
| Rate for Payer: Cigna Medicare |
$164.19
|
| Rate for Payer: Medicaid All Medicaid |
$167.84
|
| Rate for Payer: Medicare All Medicare |
$127.70
|
| Rate for Payer: Monida Allegiance |
$173.31
|
| Rate for Payer: Monida First Choice Health |
$176.96
|
| Rate for Payer: Monida Montana Health Co-op |
$173.31
|
| Rate for Payer: Monida PacificSource |
$173.31
|
|
|
CARDIAC TROPONINS CONTROL LEV
|
Facility
|
IP
|
$182.43
|
|
| Hospital Charge Code |
90196530
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$127.70 |
| Max. Negotiated Rate |
$182.43 |
| Rate for Payer: Aetna Commercial |
$173.31
|
| Rate for Payer: Aetna Medicare |
$164.19
|
| Rate for Payer: BCBS MT CHIP |
$164.19
|
| Rate for Payer: BCBS MT Closed Plan Network |
$173.31
|
| Rate for Payer: BCBS MT HealthLink |
$164.19
|
| Rate for Payer: BCBS MT Medicare |
$164.19
|
| Rate for Payer: BCBS MT POS |
$173.31
|
| Rate for Payer: BCBS MT Traditional |
$182.43
|
| Rate for Payer: Cash Price |
$164.19
|
| Rate for Payer: Cigna Commercial |
$173.31
|
| Rate for Payer: Cigna Medicare |
$164.19
|
| Rate for Payer: Medicaid All Medicaid |
$167.84
|
| Rate for Payer: Medicare All Medicare |
$127.70
|
| Rate for Payer: Monida Allegiance |
$173.31
|
| Rate for Payer: Monida First Choice Health |
$176.96
|
| Rate for Payer: Monida Montana Health Co-op |
$173.31
|
| Rate for Payer: Monida PacificSource |
$173.31
|
|
|
CARDIOLIPIN AB IGG IGM
|
Facility
|
IP
|
$42.00
|
|
|
Service Code
|
HCPCS 86147
|
| Hospital Charge Code |
4087891
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$29.40 |
| Max. Negotiated Rate |
$42.00 |
| Rate for Payer: Aetna Commercial |
$39.90
|
| Rate for Payer: Aetna Medicare |
$37.80
|
| Rate for Payer: BCBS MT CHIP |
$37.80
|
| Rate for Payer: BCBS MT Closed Plan Network |
$39.90
|
| Rate for Payer: BCBS MT HealthLink |
$37.80
|
| Rate for Payer: BCBS MT Medicare |
$37.80
|
| Rate for Payer: BCBS MT POS |
$39.90
|
| Rate for Payer: BCBS MT Traditional |
$42.00
|
| Rate for Payer: Cash Price |
$37.80
|
| Rate for Payer: Cigna Commercial |
$39.90
|
| Rate for Payer: Cigna Medicare |
$37.80
|
| Rate for Payer: Medicaid All Medicaid |
$38.64
|
| Rate for Payer: Medicare All Medicare |
$29.40
|
| Rate for Payer: Monida Allegiance |
$39.90
|
| Rate for Payer: Monida First Choice Health |
$40.74
|
| Rate for Payer: Monida Montana Health Co-op |
$39.90
|
| Rate for Payer: Monida PacificSource |
$39.90
|
|
|
CARDIOLIPIN AB IGG IGM
|
Facility
|
OP
|
$42.00
|
|
|
Service Code
|
HCPCS 86147
|
| Hospital Charge Code |
4087891
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$29.40 |
| Max. Negotiated Rate |
$42.00 |
| Rate for Payer: Aetna Commercial |
$39.90
|
| Rate for Payer: Aetna Medicare |
$37.80
|
| Rate for Payer: BCBS MT CHIP |
$37.80
|
| Rate for Payer: BCBS MT Closed Plan Network |
$39.90
|
| Rate for Payer: BCBS MT HealthLink |
$37.80
|
| Rate for Payer: BCBS MT Medicare |
$37.80
|
| Rate for Payer: BCBS MT POS |
$39.90
|
| Rate for Payer: BCBS MT Traditional |
$42.00
|
| Rate for Payer: Cash Price |
$37.80
|
| Rate for Payer: Cigna Commercial |
$39.90
|
| Rate for Payer: Cigna Medicare |
$37.80
|
| Rate for Payer: Medicaid All Medicaid |
$38.64
|
| Rate for Payer: Medicare All Medicare |
$29.40
|
| Rate for Payer: Monida Allegiance |
$39.90
|
| Rate for Payer: Monida First Choice Health |
$40.74
|
| Rate for Payer: Monida Montana Health Co-op |
$39.90
|
| Rate for Payer: Monida PacificSource |
$39.90
|
|
|
CARDIOVASCULAR STRESS TEST
|
Facility
|
OP
|
$1,372.00
|
|
|
Service Code
|
HCPCS 93017
|
| Hospital Charge Code |
5193017
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$960.40 |
| Max. Negotiated Rate |
$1,372.00 |
| Rate for Payer: Aetna Commercial |
$1,303.40
|
| Rate for Payer: Aetna Medicare |
$1,234.80
|
| Rate for Payer: BCBS MT CHIP |
$1,234.80
|
| Rate for Payer: BCBS MT Closed Plan Network |
$1,303.40
|
| Rate for Payer: BCBS MT HealthLink |
$1,234.80
|
| Rate for Payer: BCBS MT Medicare |
$1,234.80
|
| Rate for Payer: BCBS MT POS |
$1,303.40
|
| Rate for Payer: BCBS MT Traditional |
$1,372.00
|
| Rate for Payer: Cash Price |
$1,234.80
|
| Rate for Payer: Cigna Commercial |
$1,303.40
|
| Rate for Payer: Cigna Medicare |
$1,234.80
|
| Rate for Payer: Medicaid All Medicaid |
$1,262.24
|
| Rate for Payer: Medicare All Medicare |
$960.40
|
| Rate for Payer: Monida Allegiance |
$1,303.40
|
| Rate for Payer: Monida First Choice Health |
$1,330.84
|
| Rate for Payer: Monida Montana Health Co-op |
$1,303.40
|
| Rate for Payer: Monida PacificSource |
$1,303.40
|
|
|
CARDIOVASCULAR STRESS TEST
|
Facility
|
IP
|
$1,372.00
|
|
|
Service Code
|
HCPCS 93017
|
| Hospital Charge Code |
5193017
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$960.40 |
| Max. Negotiated Rate |
$1,372.00 |
| Rate for Payer: Aetna Commercial |
$1,303.40
|
| Rate for Payer: Aetna Medicare |
$1,234.80
|
| Rate for Payer: BCBS MT CHIP |
$1,234.80
|
| Rate for Payer: BCBS MT Closed Plan Network |
$1,303.40
|
| Rate for Payer: BCBS MT HealthLink |
$1,234.80
|
| Rate for Payer: BCBS MT Medicare |
$1,234.80
|
| Rate for Payer: BCBS MT POS |
$1,303.40
|
| Rate for Payer: BCBS MT Traditional |
$1,372.00
|
| Rate for Payer: Cash Price |
$1,234.80
|
| Rate for Payer: Cigna Commercial |
$1,303.40
|
| Rate for Payer: Cigna Medicare |
$1,234.80
|
| Rate for Payer: Medicaid All Medicaid |
$1,262.24
|
| Rate for Payer: Medicare All Medicare |
$960.40
|
| Rate for Payer: Monida Allegiance |
$1,303.40
|
| Rate for Payer: Monida First Choice Health |
$1,330.84
|
| Rate for Payer: Monida Montana Health Co-op |
$1,303.40
|
| Rate for Payer: Monida PacificSource |
$1,303.40
|
|
|
CARDIOVASCULAR STRESS TEST W/OUT READ
|
Facility
|
IP
|
$78.00
|
|
|
Service Code
|
HCPCS 93016
|
| Hospital Charge Code |
5193016
|
|
Hospital Revenue Code
|
482
|
| Min. Negotiated Rate |
$54.60 |
| Max. Negotiated Rate |
$78.00 |
| Rate for Payer: Aetna Commercial |
$74.10
|
| Rate for Payer: Aetna Medicare |
$70.20
|
| Rate for Payer: BCBS MT CHIP |
$70.20
|
| Rate for Payer: BCBS MT Closed Plan Network |
$74.10
|
| Rate for Payer: BCBS MT HealthLink |
$70.20
|
| Rate for Payer: BCBS MT Medicare |
$70.20
|
| Rate for Payer: BCBS MT POS |
$74.10
|
| Rate for Payer: BCBS MT Traditional |
$78.00
|
| Rate for Payer: Cash Price |
$70.20
|
| Rate for Payer: Cigna Commercial |
$74.10
|
| Rate for Payer: Cigna Medicare |
$70.20
|
| Rate for Payer: Medicaid All Medicaid |
$71.76
|
| Rate for Payer: Medicare All Medicare |
$54.60
|
| Rate for Payer: Monida Allegiance |
$74.10
|
| Rate for Payer: Monida First Choice Health |
$75.66
|
| Rate for Payer: Monida Montana Health Co-op |
$74.10
|
| Rate for Payer: Monida PacificSource |
$74.10
|
|
|
CARDIOVASCULAR STRESS TEST W/OUT READ
|
Facility
|
OP
|
$78.00
|
|
|
Service Code
|
HCPCS 93016
|
| Hospital Charge Code |
5193016
|
|
Hospital Revenue Code
|
482
|
| Min. Negotiated Rate |
$54.60 |
| Max. Negotiated Rate |
$78.00 |
| Rate for Payer: Aetna Commercial |
$74.10
|
| Rate for Payer: Aetna Medicare |
$70.20
|
| Rate for Payer: BCBS MT CHIP |
$70.20
|
| Rate for Payer: BCBS MT Closed Plan Network |
$74.10
|
| Rate for Payer: BCBS MT HealthLink |
$70.20
|
| Rate for Payer: BCBS MT Medicare |
$70.20
|
| Rate for Payer: BCBS MT POS |
$74.10
|
| Rate for Payer: BCBS MT Traditional |
$78.00
|
| Rate for Payer: Cash Price |
$70.20
|
| Rate for Payer: Cigna Commercial |
$74.10
|
| Rate for Payer: Cigna Medicare |
$70.20
|
| Rate for Payer: Medicaid All Medicaid |
$71.76
|
| Rate for Payer: Medicare All Medicare |
$54.60
|
| Rate for Payer: Monida Allegiance |
$74.10
|
| Rate for Payer: Monida First Choice Health |
$75.66
|
| Rate for Payer: Monida Montana Health Co-op |
$74.10
|
| Rate for Payer: Monida PacificSource |
$74.10
|
|
|
CARPEL TUNNEL SUPP LEFT LG
|
Facility
|
IP
|
$29.00
|
|
| Hospital Charge Code |
2893217
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$20.30 |
| Max. Negotiated Rate |
$29.00 |
| Rate for Payer: Aetna Commercial |
$27.55
|
| Rate for Payer: Aetna Medicare |
$26.10
|
| Rate for Payer: BCBS MT CHIP |
$26.10
|
| Rate for Payer: BCBS MT Closed Plan Network |
$27.55
|
| Rate for Payer: BCBS MT HealthLink |
$26.10
|
| Rate for Payer: BCBS MT Medicare |
$26.10
|
| Rate for Payer: BCBS MT POS |
$27.55
|
| Rate for Payer: BCBS MT Traditional |
$29.00
|
| Rate for Payer: Cash Price |
$26.10
|
| Rate for Payer: Cigna Commercial |
$27.55
|
| Rate for Payer: Cigna Medicare |
$26.10
|
| Rate for Payer: Medicaid All Medicaid |
$26.68
|
| Rate for Payer: Medicare All Medicare |
$20.30
|
| Rate for Payer: Monida Allegiance |
$27.55
|
| Rate for Payer: Monida First Choice Health |
$28.13
|
| Rate for Payer: Monida Montana Health Co-op |
$27.55
|
| Rate for Payer: Monida PacificSource |
$27.55
|
|
|
CARPEL TUNNEL SUPP LEFT LG
|
Facility
|
OP
|
$29.00
|
|
| Hospital Charge Code |
2893217
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$20.30 |
| Max. Negotiated Rate |
$29.00 |
| Rate for Payer: Aetna Commercial |
$27.55
|
| Rate for Payer: Aetna Medicare |
$26.10
|
| Rate for Payer: BCBS MT CHIP |
$26.10
|
| Rate for Payer: BCBS MT Closed Plan Network |
$27.55
|
| Rate for Payer: BCBS MT HealthLink |
$26.10
|
| Rate for Payer: BCBS MT Medicare |
$26.10
|
| Rate for Payer: BCBS MT POS |
$27.55
|
| Rate for Payer: BCBS MT Traditional |
$29.00
|
| Rate for Payer: Cash Price |
$26.10
|
| Rate for Payer: Cigna Commercial |
$27.55
|
| Rate for Payer: Cigna Medicare |
$26.10
|
| Rate for Payer: Medicaid All Medicaid |
$26.68
|
| Rate for Payer: Medicare All Medicare |
$20.30
|
| Rate for Payer: Monida Allegiance |
$27.55
|
| Rate for Payer: Monida First Choice Health |
$28.13
|
| Rate for Payer: Monida Montana Health Co-op |
$27.55
|
| Rate for Payer: Monida PacificSource |
$27.55
|
|
|
CARPEL TUNNEL SUPP LEFT MED
|
Facility
|
IP
|
$29.00
|
|
| Hospital Charge Code |
2893216
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$20.30 |
| Max. Negotiated Rate |
$29.00 |
| Rate for Payer: Aetna Commercial |
$27.55
|
| Rate for Payer: Aetna Medicare |
$26.10
|
| Rate for Payer: BCBS MT CHIP |
$26.10
|
| Rate for Payer: BCBS MT Closed Plan Network |
$27.55
|
| Rate for Payer: BCBS MT HealthLink |
$26.10
|
| Rate for Payer: BCBS MT Medicare |
$26.10
|
| Rate for Payer: BCBS MT POS |
$27.55
|
| Rate for Payer: BCBS MT Traditional |
$29.00
|
| Rate for Payer: Cash Price |
$26.10
|
| Rate for Payer: Cigna Commercial |
$27.55
|
| Rate for Payer: Cigna Medicare |
$26.10
|
| Rate for Payer: Medicaid All Medicaid |
$26.68
|
| Rate for Payer: Medicare All Medicare |
$20.30
|
| Rate for Payer: Monida Allegiance |
$27.55
|
| Rate for Payer: Monida First Choice Health |
$28.13
|
| Rate for Payer: Monida Montana Health Co-op |
$27.55
|
| Rate for Payer: Monida PacificSource |
$27.55
|
|
|
CARPEL TUNNEL SUPP LEFT MED
|
Facility
|
OP
|
$29.00
|
|
| Hospital Charge Code |
2893216
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$20.30 |
| Max. Negotiated Rate |
$29.00 |
| Rate for Payer: Aetna Commercial |
$27.55
|
| Rate for Payer: Aetna Medicare |
$26.10
|
| Rate for Payer: BCBS MT CHIP |
$26.10
|
| Rate for Payer: BCBS MT Closed Plan Network |
$27.55
|
| Rate for Payer: BCBS MT HealthLink |
$26.10
|
| Rate for Payer: BCBS MT Medicare |
$26.10
|
| Rate for Payer: BCBS MT POS |
$27.55
|
| Rate for Payer: BCBS MT Traditional |
$29.00
|
| Rate for Payer: Cash Price |
$26.10
|
| Rate for Payer: Cigna Commercial |
$27.55
|
| Rate for Payer: Cigna Medicare |
$26.10
|
| Rate for Payer: Medicaid All Medicaid |
$26.68
|
| Rate for Payer: Medicare All Medicare |
$20.30
|
| Rate for Payer: Monida Allegiance |
$27.55
|
| Rate for Payer: Monida First Choice Health |
$28.13
|
| Rate for Payer: Monida Montana Health Co-op |
$27.55
|
| Rate for Payer: Monida PacificSource |
$27.55
|
|
|
CARPEL TUNNEL SUPP LEFT XLG
|
Facility
|
OP
|
$29.00
|
|
| Hospital Charge Code |
2893218
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$20.30 |
| Max. Negotiated Rate |
$29.00 |
| Rate for Payer: Aetna Commercial |
$27.55
|
| Rate for Payer: Aetna Medicare |
$26.10
|
| Rate for Payer: BCBS MT CHIP |
$26.10
|
| Rate for Payer: BCBS MT Closed Plan Network |
$27.55
|
| Rate for Payer: BCBS MT HealthLink |
$26.10
|
| Rate for Payer: BCBS MT Medicare |
$26.10
|
| Rate for Payer: BCBS MT POS |
$27.55
|
| Rate for Payer: BCBS MT Traditional |
$29.00
|
| Rate for Payer: Cash Price |
$26.10
|
| Rate for Payer: Cigna Commercial |
$27.55
|
| Rate for Payer: Cigna Medicare |
$26.10
|
| Rate for Payer: Medicaid All Medicaid |
$26.68
|
| Rate for Payer: Medicare All Medicare |
$20.30
|
| Rate for Payer: Monida Allegiance |
$27.55
|
| Rate for Payer: Monida First Choice Health |
$28.13
|
| Rate for Payer: Monida Montana Health Co-op |
$27.55
|
| Rate for Payer: Monida PacificSource |
$27.55
|
|
