|
SB/NH SUBSEQUENT CARE 10 MIN (99307)
|
Facility
|
OP
|
$101.00
|
|
|
Service Code
|
CPT 99307
|
| Hospital Charge Code |
799307
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$70.70 |
| Max. Negotiated Rate |
$101.00 |
| Rate for Payer: Aetna Commercial |
$95.95
|
| Rate for Payer: Aetna Medicare |
$90.90
|
| Rate for Payer: BCBS MT CHIP |
$90.90
|
| Rate for Payer: BCBS MT Closed Plan Network |
$95.95
|
| Rate for Payer: BCBS MT HealthLink |
$90.90
|
| Rate for Payer: BCBS MT Medicare |
$90.90
|
| Rate for Payer: BCBS MT POS |
$95.95
|
| Rate for Payer: BCBS MT Traditional |
$101.00
|
| Rate for Payer: Cash Price |
$90.90
|
| Rate for Payer: Cigna Commercial |
$95.95
|
| Rate for Payer: Cigna Medicare |
$90.90
|
| Rate for Payer: Medicaid All Medicaid |
$92.92
|
| Rate for Payer: Medicare All Medicare |
$70.70
|
| Rate for Payer: Monida Allegiance |
$95.95
|
| Rate for Payer: Monida First Choice Health |
$97.97
|
| Rate for Payer: Monida Montana Health Co-op |
$95.95
|
| Rate for Payer: Monida PacificSource |
$95.95
|
|
|
SB/NH SUBSEQUENT CARE 10 MIN (99307)
|
Facility
|
IP
|
$101.00
|
|
|
Service Code
|
CPT 99307
|
| Hospital Charge Code |
799307
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$70.70 |
| Max. Negotiated Rate |
$101.00 |
| Rate for Payer: Aetna Commercial |
$95.95
|
| Rate for Payer: Aetna Medicare |
$90.90
|
| Rate for Payer: BCBS MT CHIP |
$90.90
|
| Rate for Payer: BCBS MT Closed Plan Network |
$95.95
|
| Rate for Payer: BCBS MT HealthLink |
$90.90
|
| Rate for Payer: BCBS MT Medicare |
$90.90
|
| Rate for Payer: BCBS MT POS |
$95.95
|
| Rate for Payer: BCBS MT Traditional |
$101.00
|
| Rate for Payer: Cash Price |
$90.90
|
| Rate for Payer: Cigna Commercial |
$95.95
|
| Rate for Payer: Cigna Medicare |
$90.90
|
| Rate for Payer: Medicaid All Medicaid |
$92.92
|
| Rate for Payer: Medicare All Medicare |
$70.70
|
| Rate for Payer: Monida Allegiance |
$95.95
|
| Rate for Payer: Monida First Choice Health |
$97.97
|
| Rate for Payer: Monida Montana Health Co-op |
$95.95
|
| Rate for Payer: Monida PacificSource |
$95.95
|
|
|
SB/NH SUBSEQUENT CARE HIGH-45 MIN(99310)
|
Facility
|
OP
|
$284.00
|
|
|
Service Code
|
CPT 99310
|
| Hospital Charge Code |
799310
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$198.80 |
| Max. Negotiated Rate |
$284.00 |
| Rate for Payer: Aetna Commercial |
$269.80
|
| Rate for Payer: Aetna Medicare |
$255.60
|
| Rate for Payer: BCBS MT CHIP |
$255.60
|
| Rate for Payer: BCBS MT Closed Plan Network |
$269.80
|
| Rate for Payer: BCBS MT HealthLink |
$255.60
|
| Rate for Payer: BCBS MT Medicare |
$255.60
|
| Rate for Payer: BCBS MT POS |
$269.80
|
| Rate for Payer: BCBS MT Traditional |
$284.00
|
| Rate for Payer: Cash Price |
$255.60
|
| Rate for Payer: Cigna Commercial |
$269.80
|
| Rate for Payer: Cigna Medicare |
$255.60
|
| Rate for Payer: Medicaid All Medicaid |
$261.28
|
| Rate for Payer: Medicare All Medicare |
$198.80
|
| Rate for Payer: Monida Allegiance |
$269.80
|
| Rate for Payer: Monida First Choice Health |
$275.48
|
| Rate for Payer: Monida Montana Health Co-op |
$269.80
|
| Rate for Payer: Monida PacificSource |
$269.80
|
|
|
SB/NH SUBSEQUENT CARE HIGH-45 MIN(99310)
|
Facility
|
IP
|
$284.00
|
|
|
Service Code
|
CPT 99310
|
| Hospital Charge Code |
799310
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$198.80 |
| Max. Negotiated Rate |
$284.00 |
| Rate for Payer: Aetna Commercial |
$269.80
|
| Rate for Payer: Aetna Medicare |
$255.60
|
| Rate for Payer: BCBS MT CHIP |
$255.60
|
| Rate for Payer: BCBS MT Closed Plan Network |
$269.80
|
| Rate for Payer: BCBS MT HealthLink |
$255.60
|
| Rate for Payer: BCBS MT Medicare |
$255.60
|
| Rate for Payer: BCBS MT POS |
$269.80
|
| Rate for Payer: BCBS MT Traditional |
$284.00
|
| Rate for Payer: Cash Price |
$255.60
|
| Rate for Payer: Cigna Commercial |
$269.80
|
| Rate for Payer: Cigna Medicare |
$255.60
|
| Rate for Payer: Medicaid All Medicaid |
$261.28
|
| Rate for Payer: Medicare All Medicare |
$198.80
|
| Rate for Payer: Monida Allegiance |
$269.80
|
| Rate for Payer: Monida First Choice Health |
$275.48
|
| Rate for Payer: Monida Montana Health Co-op |
$269.80
|
| Rate for Payer: Monida PacificSource |
$269.80
|
|
|
SB/NH SUBSEQUENT CARE LOW-20 MIN (99308)
|
Facility
|
IP
|
$156.00
|
|
|
Service Code
|
CPT 99308
|
| Hospital Charge Code |
799308
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$109.20 |
| Max. Negotiated Rate |
$156.00 |
| Rate for Payer: Aetna Commercial |
$148.20
|
| Rate for Payer: Aetna Medicare |
$140.40
|
| Rate for Payer: BCBS MT CHIP |
$140.40
|
| Rate for Payer: BCBS MT Closed Plan Network |
$148.20
|
| Rate for Payer: BCBS MT HealthLink |
$140.40
|
| Rate for Payer: BCBS MT Medicare |
$140.40
|
| Rate for Payer: BCBS MT POS |
$148.20
|
| Rate for Payer: BCBS MT Traditional |
$156.00
|
| Rate for Payer: Cash Price |
$140.40
|
| Rate for Payer: Cigna Commercial |
$148.20
|
| Rate for Payer: Cigna Medicare |
$140.40
|
| Rate for Payer: Medicaid All Medicaid |
$143.52
|
| Rate for Payer: Medicare All Medicare |
$109.20
|
| Rate for Payer: Monida Allegiance |
$148.20
|
| Rate for Payer: Monida First Choice Health |
$151.32
|
| Rate for Payer: Monida Montana Health Co-op |
$148.20
|
| Rate for Payer: Monida PacificSource |
$148.20
|
|
|
SB/NH SUBSEQUENT CARE LOW-20 MIN (99308)
|
Facility
|
OP
|
$156.00
|
|
|
Service Code
|
CPT 99308
|
| Hospital Charge Code |
799308
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$109.20 |
| Max. Negotiated Rate |
$156.00 |
| Rate for Payer: Aetna Commercial |
$148.20
|
| Rate for Payer: Aetna Medicare |
$140.40
|
| Rate for Payer: BCBS MT CHIP |
$140.40
|
| Rate for Payer: BCBS MT Closed Plan Network |
$148.20
|
| Rate for Payer: BCBS MT HealthLink |
$140.40
|
| Rate for Payer: BCBS MT Medicare |
$140.40
|
| Rate for Payer: BCBS MT POS |
$148.20
|
| Rate for Payer: BCBS MT Traditional |
$156.00
|
| Rate for Payer: Cash Price |
$140.40
|
| Rate for Payer: Cigna Commercial |
$148.20
|
| Rate for Payer: Cigna Medicare |
$140.40
|
| Rate for Payer: Medicaid All Medicaid |
$143.52
|
| Rate for Payer: Medicare All Medicare |
$109.20
|
| Rate for Payer: Monida Allegiance |
$148.20
|
| Rate for Payer: Monida First Choice Health |
$151.32
|
| Rate for Payer: Monida Montana Health Co-op |
$148.20
|
| Rate for Payer: Monida PacificSource |
$148.20
|
|
|
SB/NH SUBSEQUENT CARE MOD-30 MIN (99309)
|
Facility
|
IP
|
$206.00
|
|
|
Service Code
|
CPT 99309
|
| Hospital Charge Code |
799309
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$144.20 |
| Max. Negotiated Rate |
$206.00 |
| Rate for Payer: Aetna Commercial |
$195.70
|
| Rate for Payer: Aetna Medicare |
$185.40
|
| Rate for Payer: BCBS MT CHIP |
$185.40
|
| Rate for Payer: BCBS MT Closed Plan Network |
$195.70
|
| Rate for Payer: BCBS MT HealthLink |
$185.40
|
| Rate for Payer: BCBS MT Medicare |
$185.40
|
| Rate for Payer: BCBS MT POS |
$195.70
|
| Rate for Payer: BCBS MT Traditional |
$206.00
|
| Rate for Payer: Cash Price |
$185.40
|
| Rate for Payer: Cigna Commercial |
$195.70
|
| Rate for Payer: Cigna Medicare |
$185.40
|
| Rate for Payer: Medicaid All Medicaid |
$189.52
|
| Rate for Payer: Medicare All Medicare |
$144.20
|
| Rate for Payer: Monida Allegiance |
$195.70
|
| Rate for Payer: Monida First Choice Health |
$199.82
|
| Rate for Payer: Monida Montana Health Co-op |
$195.70
|
| Rate for Payer: Monida PacificSource |
$195.70
|
|
|
SB/NH SUBSEQUENT CARE MOD-30 MIN (99309)
|
Facility
|
OP
|
$206.00
|
|
|
Service Code
|
CPT 99309
|
| Hospital Charge Code |
799309
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$144.20 |
| Max. Negotiated Rate |
$206.00 |
| Rate for Payer: Aetna Commercial |
$195.70
|
| Rate for Payer: Aetna Medicare |
$185.40
|
| Rate for Payer: BCBS MT CHIP |
$185.40
|
| Rate for Payer: BCBS MT Closed Plan Network |
$195.70
|
| Rate for Payer: BCBS MT HealthLink |
$185.40
|
| Rate for Payer: BCBS MT Medicare |
$185.40
|
| Rate for Payer: BCBS MT POS |
$195.70
|
| Rate for Payer: BCBS MT Traditional |
$206.00
|
| Rate for Payer: Cash Price |
$185.40
|
| Rate for Payer: Cigna Commercial |
$195.70
|
| Rate for Payer: Cigna Medicare |
$185.40
|
| Rate for Payer: Medicaid All Medicaid |
$189.52
|
| Rate for Payer: Medicare All Medicare |
$144.20
|
| Rate for Payer: Monida Allegiance |
$195.70
|
| Rate for Payer: Monida First Choice Health |
$199.82
|
| Rate for Payer: Monida Montana Health Co-op |
$195.70
|
| Rate for Payer: Monida PacificSource |
$195.70
|
|
|
SCALPEL #10
|
Facility
|
OP
|
$11.00
|
|
| Hospital Charge Code |
80030255
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$7.70 |
| Max. Negotiated Rate |
$11.00 |
| Rate for Payer: Aetna Commercial |
$10.45
|
| Rate for Payer: Aetna Medicare |
$9.90
|
| Rate for Payer: BCBS MT CHIP |
$9.90
|
| Rate for Payer: BCBS MT Closed Plan Network |
$10.45
|
| Rate for Payer: BCBS MT HealthLink |
$9.90
|
| Rate for Payer: BCBS MT Medicare |
$9.90
|
| Rate for Payer: BCBS MT POS |
$10.45
|
| Rate for Payer: BCBS MT Traditional |
$11.00
|
| Rate for Payer: Cash Price |
$9.90
|
| Rate for Payer: Cigna Commercial |
$10.45
|
| Rate for Payer: Cigna Medicare |
$9.90
|
| Rate for Payer: Medicaid All Medicaid |
$10.12
|
| Rate for Payer: Medicare All Medicare |
$7.70
|
| Rate for Payer: Monida Allegiance |
$10.45
|
| Rate for Payer: Monida First Choice Health |
$10.67
|
| Rate for Payer: Monida Montana Health Co-op |
$10.45
|
| Rate for Payer: Monida PacificSource |
$10.45
|
|
|
SCALPEL #10
|
Facility
|
IP
|
$11.00
|
|
| Hospital Charge Code |
80030255
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$7.70 |
| Max. Negotiated Rate |
$11.00 |
| Rate for Payer: Aetna Commercial |
$10.45
|
| Rate for Payer: Aetna Medicare |
$9.90
|
| Rate for Payer: BCBS MT CHIP |
$9.90
|
| Rate for Payer: BCBS MT Closed Plan Network |
$10.45
|
| Rate for Payer: BCBS MT HealthLink |
$9.90
|
| Rate for Payer: BCBS MT Medicare |
$9.90
|
| Rate for Payer: BCBS MT POS |
$10.45
|
| Rate for Payer: BCBS MT Traditional |
$11.00
|
| Rate for Payer: Cash Price |
$9.90
|
| Rate for Payer: Cigna Commercial |
$10.45
|
| Rate for Payer: Cigna Medicare |
$9.90
|
| Rate for Payer: Medicaid All Medicaid |
$10.12
|
| Rate for Payer: Medicare All Medicare |
$7.70
|
| Rate for Payer: Monida Allegiance |
$10.45
|
| Rate for Payer: Monida First Choice Health |
$10.67
|
| Rate for Payer: Monida Montana Health Co-op |
$10.45
|
| Rate for Payer: Monida PacificSource |
$10.45
|
|
|
SCOPOLAMINE PATCH [1 MG/3 DAYS]]
|
Facility
|
OP
|
$68.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
3000420
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$47.60 |
| Max. Negotiated Rate |
$68.00 |
| Rate for Payer: Aetna Commercial |
$64.60
|
| Rate for Payer: Aetna Medicare |
$61.20
|
| Rate for Payer: BCBS MT CHIP |
$61.20
|
| Rate for Payer: BCBS MT Closed Plan Network |
$64.60
|
| Rate for Payer: BCBS MT HealthLink |
$61.20
|
| Rate for Payer: BCBS MT Medicare |
$61.20
|
| Rate for Payer: BCBS MT POS |
$64.60
|
| Rate for Payer: BCBS MT Traditional |
$68.00
|
| Rate for Payer: Cash Price |
$61.20
|
| Rate for Payer: Cigna Commercial |
$64.60
|
| Rate for Payer: Cigna Medicare |
$61.20
|
| Rate for Payer: Medicaid All Medicaid |
$62.56
|
| Rate for Payer: Medicare All Medicare |
$47.60
|
| Rate for Payer: Monida Allegiance |
$64.60
|
| Rate for Payer: Monida First Choice Health |
$65.96
|
| Rate for Payer: Monida Montana Health Co-op |
$64.60
|
| Rate for Payer: Monida PacificSource |
$64.60
|
|
|
SCOPOLAMINE PATCH [1 MG/3 DAYS]]
|
Facility
|
IP
|
$68.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
3000420
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$47.60 |
| Max. Negotiated Rate |
$68.00 |
| Rate for Payer: Aetna Commercial |
$64.60
|
| Rate for Payer: Aetna Medicare |
$61.20
|
| Rate for Payer: BCBS MT CHIP |
$61.20
|
| Rate for Payer: BCBS MT Closed Plan Network |
$64.60
|
| Rate for Payer: BCBS MT HealthLink |
$61.20
|
| Rate for Payer: BCBS MT Medicare |
$61.20
|
| Rate for Payer: BCBS MT POS |
$64.60
|
| Rate for Payer: BCBS MT Traditional |
$68.00
|
| Rate for Payer: Cash Price |
$61.20
|
| Rate for Payer: Cigna Commercial |
$64.60
|
| Rate for Payer: Cigna Medicare |
$61.20
|
| Rate for Payer: Medicaid All Medicaid |
$62.56
|
| Rate for Payer: Medicare All Medicare |
$47.60
|
| Rate for Payer: Monida Allegiance |
$64.60
|
| Rate for Payer: Monida First Choice Health |
$65.96
|
| Rate for Payer: Monida Montana Health Co-op |
$64.60
|
| Rate for Payer: Monida PacificSource |
$64.60
|
|
|
SCREENING HEARING
|
Facility
|
OP
|
$45.00
|
|
|
Service Code
|
CPT 92551
|
| Hospital Charge Code |
8092551
|
|
Hospital Revenue Code
|
521
|
| 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
|
|
|
SCREENING HEARING
|
Facility
|
IP
|
$45.00
|
|
|
Service Code
|
CPT 92551
|
| Hospital Charge Code |
8092551
|
|
Hospital Revenue Code
|
521
|
| 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
|
|
|
SCREENING VISUAL
|
Facility
|
IP
|
$18.00
|
|
|
Service Code
|
CPT 99173
|
| Hospital Charge Code |
8099173
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$12.60 |
| Max. Negotiated Rate |
$18.00 |
| Rate for Payer: Aetna Commercial |
$17.10
|
| Rate for Payer: Aetna Medicare |
$16.20
|
| Rate for Payer: BCBS MT CHIP |
$16.20
|
| Rate for Payer: BCBS MT Closed Plan Network |
$17.10
|
| Rate for Payer: BCBS MT HealthLink |
$16.20
|
| Rate for Payer: BCBS MT Medicare |
$16.20
|
| Rate for Payer: BCBS MT POS |
$17.10
|
| Rate for Payer: BCBS MT Traditional |
$18.00
|
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Cigna Commercial |
$17.10
|
| Rate for Payer: Cigna Medicare |
$16.20
|
| Rate for Payer: Medicaid All Medicaid |
$16.56
|
| Rate for Payer: Medicare All Medicare |
$12.60
|
| Rate for Payer: Monida Allegiance |
$17.10
|
| Rate for Payer: Monida First Choice Health |
$17.46
|
| Rate for Payer: Monida Montana Health Co-op |
$17.10
|
| Rate for Payer: Monida PacificSource |
$17.10
|
|
|
SCREENING VISUAL
|
Facility
|
OP
|
$18.00
|
|
|
Service Code
|
CPT 99173
|
| Hospital Charge Code |
8099173
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$12.60 |
| Max. Negotiated Rate |
$18.00 |
| Rate for Payer: Aetna Commercial |
$17.10
|
| Rate for Payer: Aetna Medicare |
$16.20
|
| Rate for Payer: BCBS MT CHIP |
$16.20
|
| Rate for Payer: BCBS MT Closed Plan Network |
$17.10
|
| Rate for Payer: BCBS MT HealthLink |
$16.20
|
| Rate for Payer: BCBS MT Medicare |
$16.20
|
| Rate for Payer: BCBS MT POS |
$17.10
|
| Rate for Payer: BCBS MT Traditional |
$18.00
|
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Cigna Commercial |
$17.10
|
| Rate for Payer: Cigna Medicare |
$16.20
|
| Rate for Payer: Medicaid All Medicaid |
$16.56
|
| Rate for Payer: Medicare All Medicare |
$12.60
|
| Rate for Payer: Monida Allegiance |
$17.10
|
| Rate for Payer: Monida First Choice Health |
$17.46
|
| Rate for Payer: Monida Montana Health Co-op |
$17.10
|
| Rate for Payer: Monida PacificSource |
$17.10
|
|
|
SEASONAL ALLERGENS
|
Facility
|
OP
|
$188.00
|
|
|
Service Code
|
CPT 86003
|
| Hospital Charge Code |
4088027
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$131.60 |
| Max. Negotiated Rate |
$188.00 |
| Rate for Payer: Aetna Commercial |
$178.60
|
| Rate for Payer: Aetna Medicare |
$169.20
|
| Rate for Payer: BCBS MT CHIP |
$169.20
|
| Rate for Payer: BCBS MT Closed Plan Network |
$178.60
|
| Rate for Payer: BCBS MT HealthLink |
$169.20
|
| Rate for Payer: BCBS MT Medicare |
$169.20
|
| Rate for Payer: BCBS MT POS |
$178.60
|
| Rate for Payer: BCBS MT Traditional |
$188.00
|
| Rate for Payer: Cash Price |
$169.20
|
| Rate for Payer: Cigna Commercial |
$178.60
|
| Rate for Payer: Cigna Medicare |
$169.20
|
| Rate for Payer: Medicaid All Medicaid |
$172.96
|
| Rate for Payer: Medicare All Medicare |
$131.60
|
| Rate for Payer: Monida Allegiance |
$178.60
|
| Rate for Payer: Monida First Choice Health |
$182.36
|
| Rate for Payer: Monida Montana Health Co-op |
$178.60
|
| Rate for Payer: Monida PacificSource |
$178.60
|
|
|
SEASONAL ALLERGENS
|
Facility
|
IP
|
$188.00
|
|
|
Service Code
|
CPT 86003
|
| Hospital Charge Code |
4088027
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$131.60 |
| Max. Negotiated Rate |
$188.00 |
| Rate for Payer: Aetna Commercial |
$178.60
|
| Rate for Payer: Aetna Medicare |
$169.20
|
| Rate for Payer: BCBS MT CHIP |
$169.20
|
| Rate for Payer: BCBS MT Closed Plan Network |
$178.60
|
| Rate for Payer: BCBS MT HealthLink |
$169.20
|
| Rate for Payer: BCBS MT Medicare |
$169.20
|
| Rate for Payer: BCBS MT POS |
$178.60
|
| Rate for Payer: BCBS MT Traditional |
$188.00
|
| Rate for Payer: Cash Price |
$169.20
|
| Rate for Payer: Cigna Commercial |
$178.60
|
| Rate for Payer: Cigna Medicare |
$169.20
|
| Rate for Payer: Medicaid All Medicaid |
$172.96
|
| Rate for Payer: Medicare All Medicare |
$131.60
|
| Rate for Payer: Monida Allegiance |
$178.60
|
| Rate for Payer: Monida First Choice Health |
$182.36
|
| Rate for Payer: Monida Montana Health Co-op |
$178.60
|
| Rate for Payer: Monida PacificSource |
$178.60
|
|
|
SELENIUM (716910)
|
Facility
|
OP
|
$180.00
|
|
|
Service Code
|
CPT 84255
|
| Hospital Charge Code |
4084255
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$126.00 |
| Max. Negotiated Rate |
$180.00 |
| Rate for Payer: Aetna Commercial |
$171.00
|
| Rate for Payer: Aetna Medicare |
$162.00
|
| Rate for Payer: BCBS MT CHIP |
$162.00
|
| Rate for Payer: BCBS MT Closed Plan Network |
$171.00
|
| Rate for Payer: BCBS MT HealthLink |
$162.00
|
| Rate for Payer: BCBS MT Medicare |
$162.00
|
| Rate for Payer: BCBS MT POS |
$171.00
|
| Rate for Payer: BCBS MT Traditional |
$180.00
|
| Rate for Payer: Cash Price |
$162.00
|
| Rate for Payer: Cigna Commercial |
$171.00
|
| Rate for Payer: Cigna Medicare |
$162.00
|
| Rate for Payer: Medicaid All Medicaid |
$165.60
|
| Rate for Payer: Medicare All Medicare |
$126.00
|
| Rate for Payer: Monida Allegiance |
$171.00
|
| Rate for Payer: Monida First Choice Health |
$174.60
|
| Rate for Payer: Monida Montana Health Co-op |
$171.00
|
| Rate for Payer: Monida PacificSource |
$171.00
|
|
|
SELENIUM (716910)
|
Facility
|
IP
|
$180.00
|
|
|
Service Code
|
CPT 84255
|
| Hospital Charge Code |
4084255
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$126.00 |
| Max. Negotiated Rate |
$180.00 |
| Rate for Payer: Aetna Commercial |
$171.00
|
| Rate for Payer: Aetna Medicare |
$162.00
|
| Rate for Payer: BCBS MT CHIP |
$162.00
|
| Rate for Payer: BCBS MT Closed Plan Network |
$171.00
|
| Rate for Payer: BCBS MT HealthLink |
$162.00
|
| Rate for Payer: BCBS MT Medicare |
$162.00
|
| Rate for Payer: BCBS MT POS |
$171.00
|
| Rate for Payer: BCBS MT Traditional |
$180.00
|
| Rate for Payer: Cash Price |
$162.00
|
| Rate for Payer: Cigna Commercial |
$171.00
|
| Rate for Payer: Cigna Medicare |
$162.00
|
| Rate for Payer: Medicaid All Medicaid |
$165.60
|
| Rate for Payer: Medicare All Medicare |
$126.00
|
| Rate for Payer: Monida Allegiance |
$171.00
|
| Rate for Payer: Monida First Choice Health |
$174.60
|
| Rate for Payer: Monida Montana Health Co-op |
$171.00
|
| Rate for Payer: Monida PacificSource |
$171.00
|
|
|
SEMAGLUTIDE SQ INJ [1 MG/0.75 ML] SP ORD
|
Facility
|
IP
|
$1,676.00
|
|
|
Service Code
|
HCPCS J3590
|
| Hospital Charge Code |
3000605
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1,173.20 |
| Max. Negotiated Rate |
$1,676.00 |
| Rate for Payer: Aetna Commercial |
$1,592.20
|
| Rate for Payer: Aetna Medicare |
$1,508.40
|
| Rate for Payer: BCBS MT CHIP |
$1,508.40
|
| Rate for Payer: BCBS MT Closed Plan Network |
$1,592.20
|
| Rate for Payer: BCBS MT HealthLink |
$1,508.40
|
| Rate for Payer: BCBS MT Medicare |
$1,508.40
|
| Rate for Payer: BCBS MT POS |
$1,592.20
|
| Rate for Payer: BCBS MT Traditional |
$1,676.00
|
| Rate for Payer: Cash Price |
$1,508.40
|
| Rate for Payer: Cigna Commercial |
$1,592.20
|
| Rate for Payer: Cigna Medicare |
$1,508.40
|
| Rate for Payer: Medicaid All Medicaid |
$1,541.92
|
| Rate for Payer: Medicare All Medicare |
$1,173.20
|
| Rate for Payer: Monida Allegiance |
$1,592.20
|
| Rate for Payer: Monida First Choice Health |
$1,625.72
|
| Rate for Payer: Monida Montana Health Co-op |
$1,592.20
|
| Rate for Payer: Monida PacificSource |
$1,592.20
|
|
|
SEMAGLUTIDE SQ INJ [1 MG/0.75 ML] SP ORD
|
Facility
|
OP
|
$1,676.00
|
|
|
Service Code
|
HCPCS J3590
|
| Hospital Charge Code |
3000605
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1,173.20 |
| Max. Negotiated Rate |
$1,676.00 |
| Rate for Payer: Aetna Commercial |
$1,592.20
|
| Rate for Payer: Aetna Medicare |
$1,508.40
|
| Rate for Payer: BCBS MT CHIP |
$1,508.40
|
| Rate for Payer: BCBS MT Closed Plan Network |
$1,592.20
|
| Rate for Payer: BCBS MT HealthLink |
$1,508.40
|
| Rate for Payer: BCBS MT Medicare |
$1,508.40
|
| Rate for Payer: BCBS MT POS |
$1,592.20
|
| Rate for Payer: BCBS MT Traditional |
$1,676.00
|
| Rate for Payer: Cash Price |
$1,508.40
|
| Rate for Payer: Cigna Commercial |
$1,592.20
|
| Rate for Payer: Cigna Medicare |
$1,508.40
|
| Rate for Payer: Medicaid All Medicaid |
$1,541.92
|
| Rate for Payer: Medicare All Medicare |
$1,173.20
|
| Rate for Payer: Monida Allegiance |
$1,592.20
|
| Rate for Payer: Monida First Choice Health |
$1,625.72
|
| Rate for Payer: Monida Montana Health Co-op |
$1,592.20
|
| Rate for Payer: Monida PacificSource |
$1,592.20
|
|
|
SENNA TAB [8.6 MG]
|
Facility
|
OP
|
$8.00
|
|
|
Service Code
|
HCPCS A9150
|
| Hospital Charge Code |
3000512
|
|
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
|
|
|
SENNA TAB [8.6 MG]
|
Facility
|
IP
|
$8.00
|
|
|
Service Code
|
HCPCS A9150
|
| Hospital Charge Code |
3000512
|
|
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
|
|
|
.SENSITIVITY, EACH ORGANISM
|
Facility
|
IP
|
$63.00
|
|
|
Service Code
|
CPT 87186
|
| Hospital Charge Code |
4087186
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$44.10 |
| Max. Negotiated Rate |
$63.00 |
| Rate for Payer: Aetna Commercial |
$59.85
|
| Rate for Payer: Aetna Medicare |
$56.70
|
| Rate for Payer: BCBS MT CHIP |
$56.70
|
| Rate for Payer: BCBS MT Closed Plan Network |
$59.85
|
| Rate for Payer: BCBS MT HealthLink |
$56.70
|
| Rate for Payer: BCBS MT Medicare |
$56.70
|
| Rate for Payer: BCBS MT POS |
$59.85
|
| Rate for Payer: BCBS MT Traditional |
$63.00
|
| Rate for Payer: Cash Price |
$56.70
|
| Rate for Payer: Cigna Commercial |
$59.85
|
| Rate for Payer: Cigna Medicare |
$56.70
|
| Rate for Payer: Medicaid All Medicaid |
$57.96
|
| Rate for Payer: Medicare All Medicare |
$44.10
|
| Rate for Payer: Monida Allegiance |
$59.85
|
| Rate for Payer: Monida First Choice Health |
$61.11
|
| Rate for Payer: Monida Montana Health Co-op |
$59.85
|
| Rate for Payer: Monida PacificSource |
$59.85
|
|
