|
ROTAVIRUS ORAL - ROTATEQ (3DOSE)
|
Facility
|
OP
|
$147.00
|
|
|
Service Code
|
CPT 90680
|
| Hospital Charge Code |
8090680
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$102.90 |
| Max. Negotiated Rate |
$147.00 |
| Rate for Payer: Aetna Commercial |
$139.65
|
| Rate for Payer: Aetna Medicare |
$132.30
|
| Rate for Payer: BCBS MT CHIP |
$132.30
|
| Rate for Payer: BCBS MT Closed Plan Network |
$139.65
|
| Rate for Payer: BCBS MT HealthLink |
$132.30
|
| Rate for Payer: BCBS MT Medicare |
$132.30
|
| Rate for Payer: BCBS MT POS |
$139.65
|
| Rate for Payer: BCBS MT Traditional |
$147.00
|
| Rate for Payer: Cash Price |
$132.30
|
| Rate for Payer: Cigna Commercial |
$139.65
|
| Rate for Payer: Cigna Medicare |
$132.30
|
| Rate for Payer: Medicaid All Medicaid |
$135.24
|
| Rate for Payer: Medicare All Medicare |
$102.90
|
| Rate for Payer: Monida Allegiance |
$139.65
|
| Rate for Payer: Monida First Choice Health |
$142.59
|
| Rate for Payer: Monida Montana Health Co-op |
$139.65
|
| Rate for Payer: Monida PacificSource |
$139.65
|
|
|
ROTAVIRUS ORAL - ROTATEQ (3DOSE)
|
Facility
|
IP
|
$147.00
|
|
|
Service Code
|
CPT 90680
|
| Hospital Charge Code |
8090680
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$102.90 |
| Max. Negotiated Rate |
$147.00 |
| Rate for Payer: Aetna Commercial |
$139.65
|
| Rate for Payer: Aetna Medicare |
$132.30
|
| Rate for Payer: BCBS MT CHIP |
$132.30
|
| Rate for Payer: BCBS MT Closed Plan Network |
$139.65
|
| Rate for Payer: BCBS MT HealthLink |
$132.30
|
| Rate for Payer: BCBS MT Medicare |
$132.30
|
| Rate for Payer: BCBS MT POS |
$139.65
|
| Rate for Payer: BCBS MT Traditional |
$147.00
|
| Rate for Payer: Cash Price |
$132.30
|
| Rate for Payer: Cigna Commercial |
$139.65
|
| Rate for Payer: Cigna Medicare |
$132.30
|
| Rate for Payer: Medicaid All Medicaid |
$135.24
|
| Rate for Payer: Medicare All Medicare |
$102.90
|
| Rate for Payer: Monida Allegiance |
$139.65
|
| Rate for Payer: Monida First Choice Health |
$142.59
|
| Rate for Payer: Monida Montana Health Co-op |
$139.65
|
| Rate for Payer: Monida PacificSource |
$139.65
|
|
|
RPR QUALI RVMC
|
Facility
|
IP
|
$110.00
|
|
|
Service Code
|
CPT 86592
|
| Hospital Charge Code |
4087918
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$77.00 |
| Max. Negotiated Rate |
$110.00 |
| Rate for Payer: Aetna Commercial |
$104.50
|
| Rate for Payer: Aetna Medicare |
$99.00
|
| Rate for Payer: BCBS MT CHIP |
$99.00
|
| Rate for Payer: BCBS MT Closed Plan Network |
$104.50
|
| Rate for Payer: BCBS MT HealthLink |
$99.00
|
| Rate for Payer: BCBS MT Medicare |
$99.00
|
| Rate for Payer: BCBS MT POS |
$104.50
|
| Rate for Payer: BCBS MT Traditional |
$110.00
|
| Rate for Payer: Cash Price |
$99.00
|
| Rate for Payer: Cigna Commercial |
$104.50
|
| Rate for Payer: Cigna Medicare |
$99.00
|
| Rate for Payer: Medicaid All Medicaid |
$101.20
|
| Rate for Payer: Medicare All Medicare |
$77.00
|
| Rate for Payer: Monida Allegiance |
$104.50
|
| Rate for Payer: Monida First Choice Health |
$106.70
|
| Rate for Payer: Monida Montana Health Co-op |
$104.50
|
| Rate for Payer: Monida PacificSource |
$104.50
|
|
|
RPR QUALI RVMC
|
Facility
|
OP
|
$110.00
|
|
|
Service Code
|
CPT 86592
|
| Hospital Charge Code |
4087918
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$77.00 |
| Max. Negotiated Rate |
$110.00 |
| Rate for Payer: Aetna Commercial |
$104.50
|
| Rate for Payer: Aetna Medicare |
$99.00
|
| Rate for Payer: BCBS MT CHIP |
$99.00
|
| Rate for Payer: BCBS MT Closed Plan Network |
$104.50
|
| Rate for Payer: BCBS MT HealthLink |
$99.00
|
| Rate for Payer: BCBS MT Medicare |
$99.00
|
| Rate for Payer: BCBS MT POS |
$104.50
|
| Rate for Payer: BCBS MT Traditional |
$110.00
|
| Rate for Payer: Cash Price |
$99.00
|
| Rate for Payer: Cigna Commercial |
$104.50
|
| Rate for Payer: Cigna Medicare |
$99.00
|
| Rate for Payer: Medicaid All Medicaid |
$101.20
|
| Rate for Payer: Medicare All Medicare |
$77.00
|
| Rate for Payer: Monida Allegiance |
$104.50
|
| Rate for Payer: Monida First Choice Health |
$106.70
|
| Rate for Payer: Monida Montana Health Co-op |
$104.50
|
| Rate for Payer: Monida PacificSource |
$104.50
|
|
|
RPR, QUALITATIVE (006072)
|
Facility
|
IP
|
$110.00
|
|
|
Service Code
|
CPT 86592
|
| Hospital Charge Code |
4086592
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$77.00 |
| Max. Negotiated Rate |
$110.00 |
| Rate for Payer: Aetna Commercial |
$104.50
|
| Rate for Payer: Aetna Medicare |
$99.00
|
| Rate for Payer: BCBS MT CHIP |
$99.00
|
| Rate for Payer: BCBS MT Closed Plan Network |
$104.50
|
| Rate for Payer: BCBS MT HealthLink |
$99.00
|
| Rate for Payer: BCBS MT Medicare |
$99.00
|
| Rate for Payer: BCBS MT POS |
$104.50
|
| Rate for Payer: BCBS MT Traditional |
$110.00
|
| Rate for Payer: Cash Price |
$99.00
|
| Rate for Payer: Cigna Commercial |
$104.50
|
| Rate for Payer: Cigna Medicare |
$99.00
|
| Rate for Payer: Medicaid All Medicaid |
$101.20
|
| Rate for Payer: Medicare All Medicare |
$77.00
|
| Rate for Payer: Monida Allegiance |
$104.50
|
| Rate for Payer: Monida First Choice Health |
$106.70
|
| Rate for Payer: Monida Montana Health Co-op |
$104.50
|
| Rate for Payer: Monida PacificSource |
$104.50
|
|
|
RPR, QUALITATIVE (006072)
|
Facility
|
OP
|
$110.00
|
|
|
Service Code
|
CPT 86592
|
| Hospital Charge Code |
4086592
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$77.00 |
| Max. Negotiated Rate |
$110.00 |
| Rate for Payer: Aetna Commercial |
$104.50
|
| Rate for Payer: Aetna Medicare |
$99.00
|
| Rate for Payer: BCBS MT CHIP |
$99.00
|
| Rate for Payer: BCBS MT Closed Plan Network |
$104.50
|
| Rate for Payer: BCBS MT HealthLink |
$99.00
|
| Rate for Payer: BCBS MT Medicare |
$99.00
|
| Rate for Payer: BCBS MT POS |
$104.50
|
| Rate for Payer: BCBS MT Traditional |
$110.00
|
| Rate for Payer: Cash Price |
$99.00
|
| Rate for Payer: Cigna Commercial |
$104.50
|
| Rate for Payer: Cigna Medicare |
$99.00
|
| Rate for Payer: Medicaid All Medicaid |
$101.20
|
| Rate for Payer: Medicare All Medicare |
$77.00
|
| Rate for Payer: Monida Allegiance |
$104.50
|
| Rate for Payer: Monida First Choice Health |
$106.70
|
| Rate for Payer: Monida Montana Health Co-op |
$104.50
|
| Rate for Payer: Monida PacificSource |
$104.50
|
|
|
RPR, QUALITATIVE CONFI
|
Facility
|
OP
|
$111.00
|
|
|
Service Code
|
CPT 86592
|
| Hospital Charge Code |
4087907
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$77.70 |
| Max. Negotiated Rate |
$111.00 |
| Rate for Payer: Aetna Commercial |
$105.45
|
| Rate for Payer: Aetna Medicare |
$99.90
|
| Rate for Payer: BCBS MT CHIP |
$99.90
|
| Rate for Payer: BCBS MT Closed Plan Network |
$105.45
|
| Rate for Payer: BCBS MT HealthLink |
$99.90
|
| Rate for Payer: BCBS MT Medicare |
$99.90
|
| Rate for Payer: BCBS MT POS |
$105.45
|
| Rate for Payer: BCBS MT Traditional |
$111.00
|
| Rate for Payer: Cash Price |
$99.90
|
| Rate for Payer: Cigna Commercial |
$105.45
|
| Rate for Payer: Cigna Medicare |
$99.90
|
| Rate for Payer: Medicaid All Medicaid |
$102.12
|
| Rate for Payer: Medicare All Medicare |
$77.70
|
| Rate for Payer: Monida Allegiance |
$105.45
|
| Rate for Payer: Monida First Choice Health |
$107.67
|
| Rate for Payer: Monida Montana Health Co-op |
$105.45
|
| Rate for Payer: Monida PacificSource |
$105.45
|
|
|
RPR, QUALITATIVE CONFI
|
Facility
|
IP
|
$111.00
|
|
|
Service Code
|
CPT 86592
|
| Hospital Charge Code |
4087907
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$77.70 |
| Max. Negotiated Rate |
$111.00 |
| Rate for Payer: Aetna Commercial |
$105.45
|
| Rate for Payer: Aetna Medicare |
$99.90
|
| Rate for Payer: BCBS MT CHIP |
$99.90
|
| Rate for Payer: BCBS MT Closed Plan Network |
$105.45
|
| Rate for Payer: BCBS MT HealthLink |
$99.90
|
| Rate for Payer: BCBS MT Medicare |
$99.90
|
| Rate for Payer: BCBS MT POS |
$105.45
|
| Rate for Payer: BCBS MT Traditional |
$111.00
|
| Rate for Payer: Cash Price |
$99.90
|
| Rate for Payer: Cigna Commercial |
$105.45
|
| Rate for Payer: Cigna Medicare |
$99.90
|
| Rate for Payer: Medicaid All Medicaid |
$102.12
|
| Rate for Payer: Medicare All Medicare |
$77.70
|
| Rate for Payer: Monida Allegiance |
$105.45
|
| Rate for Payer: Monida First Choice Health |
$107.67
|
| Rate for Payer: Monida Montana Health Co-op |
$105.45
|
| Rate for Payer: Monida PacificSource |
$105.45
|
|
|
RUBELLA AB, IGG (006197)
|
Facility
|
IP
|
$66.00
|
|
|
Service Code
|
CPT 86762
|
| Hospital Charge Code |
4086762
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$46.20 |
| Max. Negotiated Rate |
$66.00 |
| Rate for Payer: Aetna Commercial |
$62.70
|
| Rate for Payer: Aetna Medicare |
$59.40
|
| Rate for Payer: BCBS MT CHIP |
$59.40
|
| Rate for Payer: BCBS MT Closed Plan Network |
$62.70
|
| Rate for Payer: BCBS MT HealthLink |
$59.40
|
| Rate for Payer: BCBS MT Medicare |
$59.40
|
| Rate for Payer: BCBS MT POS |
$62.70
|
| Rate for Payer: BCBS MT Traditional |
$66.00
|
| Rate for Payer: Cash Price |
$59.40
|
| Rate for Payer: Cigna Commercial |
$62.70
|
| Rate for Payer: Cigna Medicare |
$59.40
|
| Rate for Payer: Medicaid All Medicaid |
$60.72
|
| Rate for Payer: Medicare All Medicare |
$46.20
|
| Rate for Payer: Monida Allegiance |
$62.70
|
| Rate for Payer: Monida First Choice Health |
$64.02
|
| Rate for Payer: Monida Montana Health Co-op |
$62.70
|
| Rate for Payer: Monida PacificSource |
$62.70
|
|
|
RUBELLA AB, IGG (006197)
|
Facility
|
OP
|
$66.00
|
|
|
Service Code
|
CPT 86762
|
| Hospital Charge Code |
4086762
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$46.20 |
| Max. Negotiated Rate |
$66.00 |
| Rate for Payer: Aetna Commercial |
$62.70
|
| Rate for Payer: Aetna Medicare |
$59.40
|
| Rate for Payer: BCBS MT CHIP |
$59.40
|
| Rate for Payer: BCBS MT Closed Plan Network |
$62.70
|
| Rate for Payer: BCBS MT HealthLink |
$59.40
|
| Rate for Payer: BCBS MT Medicare |
$59.40
|
| Rate for Payer: BCBS MT POS |
$62.70
|
| Rate for Payer: BCBS MT Traditional |
$66.00
|
| Rate for Payer: Cash Price |
$59.40
|
| Rate for Payer: Cigna Commercial |
$62.70
|
| Rate for Payer: Cigna Medicare |
$59.40
|
| Rate for Payer: Medicaid All Medicaid |
$60.72
|
| Rate for Payer: Medicare All Medicare |
$46.20
|
| Rate for Payer: Monida Allegiance |
$62.70
|
| Rate for Payer: Monida First Choice Health |
$64.02
|
| Rate for Payer: Monida Montana Health Co-op |
$62.70
|
| Rate for Payer: Monida PacificSource |
$62.70
|
|
|
SACRO-LUMBAR SUPPORT
|
Facility
|
IP
|
$127.00
|
|
|
Service Code
|
HCPCS L0625
|
| Hospital Charge Code |
8000625
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$88.90 |
| Max. Negotiated Rate |
$127.00 |
| Rate for Payer: Aetna Commercial |
$120.65
|
| Rate for Payer: Aetna Medicare |
$114.30
|
| Rate for Payer: BCBS MT CHIP |
$114.30
|
| Rate for Payer: BCBS MT Closed Plan Network |
$120.65
|
| Rate for Payer: BCBS MT HealthLink |
$114.30
|
| Rate for Payer: BCBS MT Medicare |
$114.30
|
| Rate for Payer: BCBS MT POS |
$120.65
|
| Rate for Payer: BCBS MT Traditional |
$127.00
|
| Rate for Payer: Cash Price |
$114.30
|
| Rate for Payer: Cigna Commercial |
$120.65
|
| Rate for Payer: Cigna Medicare |
$114.30
|
| Rate for Payer: Medicaid All Medicaid |
$116.84
|
| Rate for Payer: Medicare All Medicare |
$88.90
|
| Rate for Payer: Monida Allegiance |
$120.65
|
| Rate for Payer: Monida First Choice Health |
$123.19
|
| Rate for Payer: Monida Montana Health Co-op |
$120.65
|
| Rate for Payer: Monida PacificSource |
$120.65
|
|
|
SACRO-LUMBAR SUPPORT
|
Facility
|
OP
|
$127.00
|
|
|
Service Code
|
HCPCS L0625
|
| Hospital Charge Code |
8000625
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$88.90 |
| Max. Negotiated Rate |
$127.00 |
| Rate for Payer: Aetna Commercial |
$120.65
|
| Rate for Payer: Aetna Medicare |
$114.30
|
| Rate for Payer: BCBS MT CHIP |
$114.30
|
| Rate for Payer: BCBS MT Closed Plan Network |
$120.65
|
| Rate for Payer: BCBS MT HealthLink |
$114.30
|
| Rate for Payer: BCBS MT Medicare |
$114.30
|
| Rate for Payer: BCBS MT POS |
$120.65
|
| Rate for Payer: BCBS MT Traditional |
$127.00
|
| Rate for Payer: Cash Price |
$114.30
|
| Rate for Payer: Cigna Commercial |
$120.65
|
| Rate for Payer: Cigna Medicare |
$114.30
|
| Rate for Payer: Medicaid All Medicaid |
$116.84
|
| Rate for Payer: Medicare All Medicare |
$88.90
|
| Rate for Payer: Monida Allegiance |
$120.65
|
| Rate for Payer: Monida First Choice Health |
$123.19
|
| Rate for Payer: Monida Montana Health Co-op |
$120.65
|
| Rate for Payer: Monida PacificSource |
$120.65
|
|
|
SACUBITRIL/VALSARTAN TAB [24MG/26MG] NF
|
Facility
|
OP
|
$45.00
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
3000544
|
|
Hospital Revenue Code
|
250
|
| 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
|
|
|
SACUBITRIL/VALSARTAN TAB [24MG/26MG] NF
|
Facility
|
IP
|
$45.00
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
3000544
|
|
Hospital Revenue Code
|
250
|
| 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
|
|
|
SALICYLATE
|
Facility
|
OP
|
$174.00
|
|
|
Service Code
|
CPT 80179
|
| Hospital Charge Code |
4000044
|
|
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
|
|
|
SALICYLATE
|
Facility
|
IP
|
$174.00
|
|
|
Service Code
|
CPT 80179
|
| Hospital Charge Code |
4000044
|
|
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
|
|
|
SAM PELVIC SLING LG
|
Facility
|
OP
|
$277.00
|
|
| Hospital Charge Code |
2893494
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$193.90 |
| Max. Negotiated Rate |
$277.00 |
| Rate for Payer: Aetna Commercial |
$263.15
|
| Rate for Payer: Aetna Medicare |
$249.30
|
| Rate for Payer: BCBS MT CHIP |
$249.30
|
| Rate for Payer: BCBS MT Closed Plan Network |
$263.15
|
| Rate for Payer: BCBS MT HealthLink |
$249.30
|
| Rate for Payer: BCBS MT Medicare |
$249.30
|
| Rate for Payer: BCBS MT POS |
$263.15
|
| Rate for Payer: BCBS MT Traditional |
$277.00
|
| Rate for Payer: Cash Price |
$249.30
|
| Rate for Payer: Cigna Commercial |
$263.15
|
| Rate for Payer: Cigna Medicare |
$249.30
|
| Rate for Payer: Medicaid All Medicaid |
$254.84
|
| Rate for Payer: Medicare All Medicare |
$193.90
|
| Rate for Payer: Monida Allegiance |
$263.15
|
| Rate for Payer: Monida First Choice Health |
$268.69
|
| Rate for Payer: Monida Montana Health Co-op |
$263.15
|
| Rate for Payer: Monida PacificSource |
$263.15
|
|
|
SAM PELVIC SLING LG
|
Facility
|
IP
|
$277.00
|
|
| Hospital Charge Code |
2893494
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$193.90 |
| Max. Negotiated Rate |
$277.00 |
| Rate for Payer: Aetna Commercial |
$263.15
|
| Rate for Payer: Aetna Medicare |
$249.30
|
| Rate for Payer: BCBS MT CHIP |
$249.30
|
| Rate for Payer: BCBS MT Closed Plan Network |
$263.15
|
| Rate for Payer: BCBS MT HealthLink |
$249.30
|
| Rate for Payer: BCBS MT Medicare |
$249.30
|
| Rate for Payer: BCBS MT POS |
$263.15
|
| Rate for Payer: BCBS MT Traditional |
$277.00
|
| Rate for Payer: Cash Price |
$249.30
|
| Rate for Payer: Cigna Commercial |
$263.15
|
| Rate for Payer: Cigna Medicare |
$249.30
|
| Rate for Payer: Medicaid All Medicaid |
$254.84
|
| Rate for Payer: Medicare All Medicare |
$193.90
|
| Rate for Payer: Monida Allegiance |
$263.15
|
| Rate for Payer: Monida First Choice Health |
$268.69
|
| Rate for Payer: Monida Montana Health Co-op |
$263.15
|
| Rate for Payer: Monida PacificSource |
$263.15
|
|
|
SAM PELVIC SLING MD
|
Facility
|
IP
|
$277.00
|
|
| Hospital Charge Code |
2893493
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$193.90 |
| Max. Negotiated Rate |
$277.00 |
| Rate for Payer: Aetna Commercial |
$263.15
|
| Rate for Payer: Aetna Medicare |
$249.30
|
| Rate for Payer: BCBS MT CHIP |
$249.30
|
| Rate for Payer: BCBS MT Closed Plan Network |
$263.15
|
| Rate for Payer: BCBS MT HealthLink |
$249.30
|
| Rate for Payer: BCBS MT Medicare |
$249.30
|
| Rate for Payer: BCBS MT POS |
$263.15
|
| Rate for Payer: BCBS MT Traditional |
$277.00
|
| Rate for Payer: Cash Price |
$249.30
|
| Rate for Payer: Cigna Commercial |
$263.15
|
| Rate for Payer: Cigna Medicare |
$249.30
|
| Rate for Payer: Medicaid All Medicaid |
$254.84
|
| Rate for Payer: Medicare All Medicare |
$193.90
|
| Rate for Payer: Monida Allegiance |
$263.15
|
| Rate for Payer: Monida First Choice Health |
$268.69
|
| Rate for Payer: Monida Montana Health Co-op |
$263.15
|
| Rate for Payer: Monida PacificSource |
$263.15
|
|
|
SAM PELVIC SLING MD
|
Facility
|
OP
|
$277.00
|
|
| Hospital Charge Code |
2893493
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$193.90 |
| Max. Negotiated Rate |
$277.00 |
| Rate for Payer: Aetna Commercial |
$263.15
|
| Rate for Payer: Aetna Medicare |
$249.30
|
| Rate for Payer: BCBS MT CHIP |
$249.30
|
| Rate for Payer: BCBS MT Closed Plan Network |
$263.15
|
| Rate for Payer: BCBS MT HealthLink |
$249.30
|
| Rate for Payer: BCBS MT Medicare |
$249.30
|
| Rate for Payer: BCBS MT POS |
$263.15
|
| Rate for Payer: BCBS MT Traditional |
$277.00
|
| Rate for Payer: Cash Price |
$249.30
|
| Rate for Payer: Cigna Commercial |
$263.15
|
| Rate for Payer: Cigna Medicare |
$249.30
|
| Rate for Payer: Medicaid All Medicaid |
$254.84
|
| Rate for Payer: Medicare All Medicare |
$193.90
|
| Rate for Payer: Monida Allegiance |
$263.15
|
| Rate for Payer: Monida First Choice Health |
$268.69
|
| Rate for Payer: Monida Montana Health Co-op |
$263.15
|
| Rate for Payer: Monida PacificSource |
$263.15
|
|
|
SAM PELVIC SLING SM
|
Facility
|
OP
|
$305.00
|
|
| Hospital Charge Code |
2840119
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$213.50 |
| Max. Negotiated Rate |
$305.00 |
| Rate for Payer: Aetna Commercial |
$289.75
|
| Rate for Payer: Aetna Medicare |
$274.50
|
| Rate for Payer: BCBS MT CHIP |
$274.50
|
| Rate for Payer: BCBS MT Closed Plan Network |
$289.75
|
| Rate for Payer: BCBS MT HealthLink |
$274.50
|
| Rate for Payer: BCBS MT Medicare |
$274.50
|
| Rate for Payer: BCBS MT POS |
$289.75
|
| Rate for Payer: BCBS MT Traditional |
$305.00
|
| Rate for Payer: Cash Price |
$274.50
|
| Rate for Payer: Cigna Commercial |
$289.75
|
| Rate for Payer: Cigna Medicare |
$274.50
|
| Rate for Payer: Medicaid All Medicaid |
$280.60
|
| Rate for Payer: Medicare All Medicare |
$213.50
|
| Rate for Payer: Monida Allegiance |
$289.75
|
| Rate for Payer: Monida First Choice Health |
$295.85
|
| Rate for Payer: Monida Montana Health Co-op |
$289.75
|
| Rate for Payer: Monida PacificSource |
$289.75
|
|
|
SAM PELVIC SLING SM
|
Facility
|
IP
|
$305.00
|
|
| Hospital Charge Code |
2840119
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$213.50 |
| Max. Negotiated Rate |
$305.00 |
| Rate for Payer: Aetna Commercial |
$289.75
|
| Rate for Payer: Aetna Medicare |
$274.50
|
| Rate for Payer: BCBS MT CHIP |
$274.50
|
| Rate for Payer: BCBS MT Closed Plan Network |
$289.75
|
| Rate for Payer: BCBS MT HealthLink |
$274.50
|
| Rate for Payer: BCBS MT Medicare |
$274.50
|
| Rate for Payer: BCBS MT POS |
$289.75
|
| Rate for Payer: BCBS MT Traditional |
$305.00
|
| Rate for Payer: Cash Price |
$274.50
|
| Rate for Payer: Cigna Commercial |
$289.75
|
| Rate for Payer: Cigna Medicare |
$274.50
|
| Rate for Payer: Medicaid All Medicaid |
$280.60
|
| Rate for Payer: Medicare All Medicare |
$213.50
|
| Rate for Payer: Monida Allegiance |
$289.75
|
| Rate for Payer: Monida First Choice Health |
$295.85
|
| Rate for Payer: Monida Montana Health Co-op |
$289.75
|
| Rate for Payer: Monida PacificSource |
$289.75
|
|
|
SAM SPLINT 4 1/4'X36''
|
Facility
|
IP
|
$46.00
|
|
| Hospital Charge Code |
2893495
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$32.20 |
| Max. Negotiated Rate |
$46.00 |
| Rate for Payer: Aetna Commercial |
$43.70
|
| Rate for Payer: Aetna Medicare |
$41.40
|
| Rate for Payer: BCBS MT CHIP |
$41.40
|
| Rate for Payer: BCBS MT Closed Plan Network |
$43.70
|
| Rate for Payer: BCBS MT HealthLink |
$41.40
|
| Rate for Payer: BCBS MT Medicare |
$41.40
|
| Rate for Payer: BCBS MT POS |
$43.70
|
| Rate for Payer: BCBS MT Traditional |
$46.00
|
| Rate for Payer: Cash Price |
$41.40
|
| Rate for Payer: Cigna Commercial |
$43.70
|
| Rate for Payer: Cigna Medicare |
$41.40
|
| Rate for Payer: Medicaid All Medicaid |
$42.32
|
| Rate for Payer: Medicare All Medicare |
$32.20
|
| Rate for Payer: Monida Allegiance |
$43.70
|
| Rate for Payer: Monida First Choice Health |
$44.62
|
| Rate for Payer: Monida Montana Health Co-op |
$43.70
|
| Rate for Payer: Monida PacificSource |
$43.70
|
|
|
SAM SPLINT 4 1/4'X36''
|
Facility
|
OP
|
$46.00
|
|
| Hospital Charge Code |
2893495
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$32.20 |
| Max. Negotiated Rate |
$46.00 |
| Rate for Payer: Aetna Commercial |
$43.70
|
| Rate for Payer: Aetna Medicare |
$41.40
|
| Rate for Payer: BCBS MT CHIP |
$41.40
|
| Rate for Payer: BCBS MT Closed Plan Network |
$43.70
|
| Rate for Payer: BCBS MT HealthLink |
$41.40
|
| Rate for Payer: BCBS MT Medicare |
$41.40
|
| Rate for Payer: BCBS MT POS |
$43.70
|
| Rate for Payer: BCBS MT Traditional |
$46.00
|
| Rate for Payer: Cash Price |
$41.40
|
| Rate for Payer: Cigna Commercial |
$43.70
|
| Rate for Payer: Cigna Medicare |
$41.40
|
| Rate for Payer: Medicaid All Medicaid |
$42.32
|
| Rate for Payer: Medicare All Medicare |
$32.20
|
| Rate for Payer: Monida Allegiance |
$43.70
|
| Rate for Payer: Monida First Choice Health |
$44.62
|
| Rate for Payer: Monida Montana Health Co-op |
$43.70
|
| Rate for Payer: Monida PacificSource |
$43.70
|
|
|
SAM SPLINT 4.25'X36' FLAT
|
Facility
|
OP
|
$46.00
|
|
| Hospital Charge Code |
2893496
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$32.20 |
| Max. Negotiated Rate |
$46.00 |
| Rate for Payer: Aetna Commercial |
$43.70
|
| Rate for Payer: Aetna Medicare |
$41.40
|
| Rate for Payer: BCBS MT CHIP |
$41.40
|
| Rate for Payer: BCBS MT Closed Plan Network |
$43.70
|
| Rate for Payer: BCBS MT HealthLink |
$41.40
|
| Rate for Payer: BCBS MT Medicare |
$41.40
|
| Rate for Payer: BCBS MT POS |
$43.70
|
| Rate for Payer: BCBS MT Traditional |
$46.00
|
| Rate for Payer: Cash Price |
$41.40
|
| Rate for Payer: Cigna Commercial |
$43.70
|
| Rate for Payer: Cigna Medicare |
$41.40
|
| Rate for Payer: Medicaid All Medicaid |
$42.32
|
| Rate for Payer: Medicare All Medicare |
$32.20
|
| Rate for Payer: Monida Allegiance |
$43.70
|
| Rate for Payer: Monida First Choice Health |
$44.62
|
| Rate for Payer: Monida Montana Health Co-op |
$43.70
|
| Rate for Payer: Monida PacificSource |
$43.70
|
|
