|
SLING AND SWATHE SM
|
Facility
|
OP
|
$43.00
|
|
| Hospital Charge Code |
2840095
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$30.10 |
| Max. Negotiated Rate |
$43.00 |
| Rate for Payer: Aetna Commercial |
$40.85
|
| Rate for Payer: Aetna Medicare |
$38.70
|
| Rate for Payer: BCBS MT CHIP |
$38.70
|
| Rate for Payer: BCBS MT Closed Plan Network |
$40.85
|
| Rate for Payer: BCBS MT HealthLink |
$38.70
|
| Rate for Payer: BCBS MT Medicare |
$38.70
|
| Rate for Payer: BCBS MT POS |
$40.85
|
| Rate for Payer: BCBS MT Traditional |
$43.00
|
| Rate for Payer: Cash Price |
$38.70
|
| Rate for Payer: Cigna Commercial |
$40.85
|
| Rate for Payer: Cigna Medicare |
$38.70
|
| Rate for Payer: Medicaid All Medicaid |
$39.56
|
| Rate for Payer: Medicare All Medicare |
$30.10
|
| Rate for Payer: Monida Allegiance |
$40.85
|
| Rate for Payer: Monida First Choice Health |
$41.71
|
| Rate for Payer: Monida Montana Health Co-op |
$40.85
|
| Rate for Payer: Monida PacificSource |
$40.85
|
|
|
SMALLBORE EXTENSION SET
|
Facility
|
IP
|
$35.00
|
|
| Hospital Charge Code |
80030040
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$24.50 |
| Max. Negotiated Rate |
$35.00 |
| Rate for Payer: Aetna Commercial |
$33.25
|
| Rate for Payer: Aetna Medicare |
$31.50
|
| Rate for Payer: BCBS MT CHIP |
$31.50
|
| Rate for Payer: BCBS MT Closed Plan Network |
$33.25
|
| Rate for Payer: BCBS MT HealthLink |
$31.50
|
| Rate for Payer: BCBS MT Medicare |
$31.50
|
| Rate for Payer: BCBS MT POS |
$33.25
|
| Rate for Payer: BCBS MT Traditional |
$35.00
|
| Rate for Payer: Cash Price |
$31.50
|
| Rate for Payer: Cigna Commercial |
$33.25
|
| Rate for Payer: Cigna Medicare |
$31.50
|
| Rate for Payer: Medicaid All Medicaid |
$32.20
|
| Rate for Payer: Medicare All Medicare |
$24.50
|
| Rate for Payer: Monida Allegiance |
$33.25
|
| Rate for Payer: Monida First Choice Health |
$33.95
|
| Rate for Payer: Monida Montana Health Co-op |
$33.25
|
| Rate for Payer: Monida PacificSource |
$33.25
|
|
|
SMALLBORE EXTENSION SET
|
Facility
|
OP
|
$35.00
|
|
| Hospital Charge Code |
80030040
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$24.50 |
| Max. Negotiated Rate |
$35.00 |
| Rate for Payer: Aetna Commercial |
$33.25
|
| Rate for Payer: Aetna Medicare |
$31.50
|
| Rate for Payer: BCBS MT CHIP |
$31.50
|
| Rate for Payer: BCBS MT Closed Plan Network |
$33.25
|
| Rate for Payer: BCBS MT HealthLink |
$31.50
|
| Rate for Payer: BCBS MT Medicare |
$31.50
|
| Rate for Payer: BCBS MT POS |
$33.25
|
| Rate for Payer: BCBS MT Traditional |
$35.00
|
| Rate for Payer: Cash Price |
$31.50
|
| Rate for Payer: Cigna Commercial |
$33.25
|
| Rate for Payer: Cigna Medicare |
$31.50
|
| Rate for Payer: Medicaid All Medicaid |
$32.20
|
| Rate for Payer: Medicare All Medicare |
$24.50
|
| Rate for Payer: Monida Allegiance |
$33.25
|
| Rate for Payer: Monida First Choice Health |
$33.95
|
| Rate for Payer: Monida Montana Health Co-op |
$33.25
|
| Rate for Payer: Monida PacificSource |
$33.25
|
|
|
SMITH ANTIBODIES (016360)
|
Facility
|
IP
|
$114.00
|
|
|
Service Code
|
CPT 86235
|
| Hospital Charge Code |
4000065
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$79.80 |
| Max. Negotiated Rate |
$114.00 |
| Rate for Payer: Aetna Commercial |
$108.30
|
| Rate for Payer: Aetna Medicare |
$102.60
|
| Rate for Payer: BCBS MT CHIP |
$102.60
|
| Rate for Payer: BCBS MT Closed Plan Network |
$108.30
|
| Rate for Payer: BCBS MT HealthLink |
$102.60
|
| Rate for Payer: BCBS MT Medicare |
$102.60
|
| Rate for Payer: BCBS MT POS |
$108.30
|
| Rate for Payer: BCBS MT Traditional |
$114.00
|
| Rate for Payer: Cash Price |
$102.60
|
| Rate for Payer: Cigna Commercial |
$108.30
|
| Rate for Payer: Cigna Medicare |
$102.60
|
| Rate for Payer: Medicaid All Medicaid |
$104.88
|
| Rate for Payer: Medicare All Medicare |
$79.80
|
| Rate for Payer: Monida Allegiance |
$108.30
|
| Rate for Payer: Monida First Choice Health |
$110.58
|
| Rate for Payer: Monida Montana Health Co-op |
$108.30
|
| Rate for Payer: Monida PacificSource |
$108.30
|
|
|
SMITH ANTIBODIES (016360)
|
Facility
|
OP
|
$114.00
|
|
|
Service Code
|
CPT 86235
|
| Hospital Charge Code |
4000065
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$79.80 |
| Max. Negotiated Rate |
$114.00 |
| Rate for Payer: Aetna Commercial |
$108.30
|
| Rate for Payer: Aetna Medicare |
$102.60
|
| Rate for Payer: BCBS MT CHIP |
$102.60
|
| Rate for Payer: BCBS MT Closed Plan Network |
$108.30
|
| Rate for Payer: BCBS MT HealthLink |
$102.60
|
| Rate for Payer: BCBS MT Medicare |
$102.60
|
| Rate for Payer: BCBS MT POS |
$108.30
|
| Rate for Payer: BCBS MT Traditional |
$114.00
|
| Rate for Payer: Cash Price |
$102.60
|
| Rate for Payer: Cigna Commercial |
$108.30
|
| Rate for Payer: Cigna Medicare |
$102.60
|
| Rate for Payer: Medicaid All Medicaid |
$104.88
|
| Rate for Payer: Medicare All Medicare |
$79.80
|
| Rate for Payer: Monida Allegiance |
$108.30
|
| Rate for Payer: Monida First Choice Health |
$110.58
|
| Rate for Payer: Monida Montana Health Co-op |
$108.30
|
| Rate for Payer: Monida PacificSource |
$108.30
|
|
|
SODIUM
|
Facility
|
IP
|
$53.00
|
|
|
Service Code
|
CPT 84295
|
| Hospital Charge Code |
4084295
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$37.10 |
| Max. Negotiated Rate |
$53.00 |
| Rate for Payer: Aetna Commercial |
$50.35
|
| Rate for Payer: Aetna Medicare |
$47.70
|
| Rate for Payer: BCBS MT CHIP |
$47.70
|
| Rate for Payer: BCBS MT Closed Plan Network |
$50.35
|
| Rate for Payer: BCBS MT HealthLink |
$47.70
|
| Rate for Payer: BCBS MT Medicare |
$47.70
|
| Rate for Payer: BCBS MT POS |
$50.35
|
| Rate for Payer: BCBS MT Traditional |
$53.00
|
| Rate for Payer: Cash Price |
$47.70
|
| Rate for Payer: Cigna Commercial |
$50.35
|
| Rate for Payer: Cigna Medicare |
$47.70
|
| Rate for Payer: Medicaid All Medicaid |
$48.76
|
| Rate for Payer: Medicare All Medicare |
$37.10
|
| Rate for Payer: Monida Allegiance |
$50.35
|
| Rate for Payer: Monida First Choice Health |
$51.41
|
| Rate for Payer: Monida Montana Health Co-op |
$50.35
|
| Rate for Payer: Monida PacificSource |
$50.35
|
|
|
SODIUM
|
Facility
|
OP
|
$53.00
|
|
|
Service Code
|
CPT 84295
|
| Hospital Charge Code |
4084295
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$37.10 |
| Max. Negotiated Rate |
$53.00 |
| Rate for Payer: Aetna Commercial |
$50.35
|
| Rate for Payer: Aetna Medicare |
$47.70
|
| Rate for Payer: BCBS MT CHIP |
$47.70
|
| Rate for Payer: BCBS MT Closed Plan Network |
$50.35
|
| Rate for Payer: BCBS MT HealthLink |
$47.70
|
| Rate for Payer: BCBS MT Medicare |
$47.70
|
| Rate for Payer: BCBS MT POS |
$50.35
|
| Rate for Payer: BCBS MT Traditional |
$53.00
|
| Rate for Payer: Cash Price |
$47.70
|
| Rate for Payer: Cigna Commercial |
$50.35
|
| Rate for Payer: Cigna Medicare |
$47.70
|
| Rate for Payer: Medicaid All Medicaid |
$48.76
|
| Rate for Payer: Medicare All Medicare |
$37.10
|
| Rate for Payer: Monida Allegiance |
$50.35
|
| Rate for Payer: Monida First Choice Health |
$51.41
|
| Rate for Payer: Monida Montana Health Co-op |
$50.35
|
| Rate for Payer: Monida PacificSource |
$50.35
|
|
|
SODIUM BICARB INJ 8.4% [50 MEQ/50 ML]
|
Facility
|
IP
|
$65.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
3000428
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$45.50 |
| Max. Negotiated Rate |
$65.00 |
| Rate for Payer: Aetna Commercial |
$61.75
|
| Rate for Payer: Aetna Medicare |
$58.50
|
| Rate for Payer: BCBS MT CHIP |
$58.50
|
| Rate for Payer: BCBS MT Closed Plan Network |
$61.75
|
| Rate for Payer: BCBS MT HealthLink |
$58.50
|
| Rate for Payer: BCBS MT Medicare |
$58.50
|
| Rate for Payer: BCBS MT POS |
$61.75
|
| Rate for Payer: BCBS MT Traditional |
$65.00
|
| Rate for Payer: Cash Price |
$58.50
|
| Rate for Payer: Cigna Commercial |
$61.75
|
| Rate for Payer: Cigna Medicare |
$58.50
|
| Rate for Payer: Medicaid All Medicaid |
$59.80
|
| Rate for Payer: Medicare All Medicare |
$45.50
|
| Rate for Payer: Monida Allegiance |
$61.75
|
| Rate for Payer: Monida First Choice Health |
$63.05
|
| Rate for Payer: Monida Montana Health Co-op |
$61.75
|
| Rate for Payer: Monida PacificSource |
$61.75
|
|
|
SODIUM BICARB INJ 8.4% [50 MEQ/50 ML]
|
Facility
|
OP
|
$65.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
3000428
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$45.50 |
| Max. Negotiated Rate |
$65.00 |
| Rate for Payer: Aetna Commercial |
$61.75
|
| Rate for Payer: Aetna Medicare |
$58.50
|
| Rate for Payer: BCBS MT CHIP |
$58.50
|
| Rate for Payer: BCBS MT Closed Plan Network |
$61.75
|
| Rate for Payer: BCBS MT HealthLink |
$58.50
|
| Rate for Payer: BCBS MT Medicare |
$58.50
|
| Rate for Payer: BCBS MT POS |
$61.75
|
| Rate for Payer: BCBS MT Traditional |
$65.00
|
| Rate for Payer: Cash Price |
$58.50
|
| Rate for Payer: Cigna Commercial |
$61.75
|
| Rate for Payer: Cigna Medicare |
$58.50
|
| Rate for Payer: Medicaid All Medicaid |
$59.80
|
| Rate for Payer: Medicare All Medicare |
$45.50
|
| Rate for Payer: Monida Allegiance |
$61.75
|
| Rate for Payer: Monida First Choice Health |
$63.05
|
| Rate for Payer: Monida Montana Health Co-op |
$61.75
|
| Rate for Payer: Monida PacificSource |
$61.75
|
|
|
SODIUM BICARBONATE TAB [650 MG] NF
|
Facility
|
OP
|
$8.00
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
3007397
|
|
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
|
|
|
SODIUM BICARBONATE TAB [650 MG] NF
|
Facility
|
IP
|
$8.00
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
3007397
|
|
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
|
|
|
SODIUM CHLORIDE 0.9% NEB SOLN [3 ML]
|
Facility
|
OP
|
$8.00
|
|
|
Service Code
|
HCPCS A4216
|
| Hospital Charge Code |
3000429
|
|
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
|
|
|
SODIUM CHLORIDE 0.9% NEB SOLN [3 ML]
|
Facility
|
IP
|
$8.00
|
|
|
Service Code
|
HCPCS A4216
|
| Hospital Charge Code |
3000429
|
|
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
|
|
|
SODIUM CHLORIDE MOISTURIZING NASAL SPRAY
|
Facility
|
OP
|
$8.00
|
|
|
Service Code
|
HCPCS A9150
|
| Hospital Charge Code |
3007353
|
|
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
|
|
|
SODIUM CHLORIDE MOISTURIZING NASAL SPRAY
|
Facility
|
IP
|
$8.00
|
|
|
Service Code
|
HCPCS A9150
|
| Hospital Charge Code |
3007353
|
|
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
|
|
|
SODIUM NITRITE INJ [300 MG/10 ML]
|
Facility
|
OP
|
$26.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
3000430
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$18.20 |
| Max. Negotiated Rate |
$26.00 |
| Rate for Payer: Aetna Commercial |
$24.70
|
| Rate for Payer: Aetna Medicare |
$23.40
|
| Rate for Payer: BCBS MT CHIP |
$23.40
|
| Rate for Payer: BCBS MT Closed Plan Network |
$24.70
|
| Rate for Payer: BCBS MT HealthLink |
$23.40
|
| Rate for Payer: BCBS MT Medicare |
$23.40
|
| Rate for Payer: BCBS MT POS |
$24.70
|
| Rate for Payer: BCBS MT Traditional |
$26.00
|
| Rate for Payer: Cash Price |
$23.40
|
| Rate for Payer: Cigna Commercial |
$24.70
|
| Rate for Payer: Cigna Medicare |
$23.40
|
| Rate for Payer: Medicaid All Medicaid |
$23.92
|
| Rate for Payer: Medicare All Medicare |
$18.20
|
| Rate for Payer: Monida Allegiance |
$24.70
|
| Rate for Payer: Monida First Choice Health |
$25.22
|
| Rate for Payer: Monida Montana Health Co-op |
$24.70
|
| Rate for Payer: Monida PacificSource |
$24.70
|
|
|
SODIUM NITRITE INJ [300 MG/10 ML]
|
Facility
|
IP
|
$26.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
3000430
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$18.20 |
| Max. Negotiated Rate |
$26.00 |
| Rate for Payer: Aetna Commercial |
$24.70
|
| Rate for Payer: Aetna Medicare |
$23.40
|
| Rate for Payer: BCBS MT CHIP |
$23.40
|
| Rate for Payer: BCBS MT Closed Plan Network |
$24.70
|
| Rate for Payer: BCBS MT HealthLink |
$23.40
|
| Rate for Payer: BCBS MT Medicare |
$23.40
|
| Rate for Payer: BCBS MT POS |
$24.70
|
| Rate for Payer: BCBS MT Traditional |
$26.00
|
| Rate for Payer: Cash Price |
$23.40
|
| Rate for Payer: Cigna Commercial |
$24.70
|
| Rate for Payer: Cigna Medicare |
$23.40
|
| Rate for Payer: Medicaid All Medicaid |
$23.92
|
| Rate for Payer: Medicare All Medicare |
$18.20
|
| Rate for Payer: Monida Allegiance |
$24.70
|
| Rate for Payer: Monida First Choice Health |
$25.22
|
| Rate for Payer: Monida Montana Health Co-op |
$24.70
|
| Rate for Payer: Monida PacificSource |
$24.70
|
|
|
SODIUM PHOSPHATE ENEMA [1 OZ]
|
Facility
|
OP
|
$8.00
|
|
|
Service Code
|
HCPCS A9150
|
| Hospital Charge Code |
3000431
|
|
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
|
|
|
SODIUM PHOSPHATE ENEMA [1 OZ]
|
Facility
|
IP
|
$8.00
|
|
|
Service Code
|
HCPCS A9150
|
| Hospital Charge Code |
3000431
|
|
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
|
|
|
SODIUM POLYSTYRENE SULFONATE [15G]
|
Facility
|
IP
|
$44.00
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
3000432
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$30.80 |
| Max. Negotiated Rate |
$44.00 |
| Rate for Payer: Aetna Commercial |
$41.80
|
| Rate for Payer: Aetna Medicare |
$39.60
|
| Rate for Payer: BCBS MT CHIP |
$39.60
|
| Rate for Payer: BCBS MT Closed Plan Network |
$41.80
|
| Rate for Payer: BCBS MT HealthLink |
$39.60
|
| Rate for Payer: BCBS MT Medicare |
$39.60
|
| Rate for Payer: BCBS MT POS |
$41.80
|
| Rate for Payer: BCBS MT Traditional |
$44.00
|
| Rate for Payer: Cash Price |
$39.60
|
| Rate for Payer: Cigna Commercial |
$41.80
|
| Rate for Payer: Cigna Medicare |
$39.60
|
| Rate for Payer: Medicaid All Medicaid |
$40.48
|
| Rate for Payer: Medicare All Medicare |
$30.80
|
| Rate for Payer: Monida Allegiance |
$41.80
|
| Rate for Payer: Monida First Choice Health |
$42.68
|
| Rate for Payer: Monida Montana Health Co-op |
$41.80
|
| Rate for Payer: Monida PacificSource |
$41.80
|
|
|
SODIUM POLYSTYRENE SULFONATE [15G]
|
Facility
|
OP
|
$44.00
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
3000432
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$30.80 |
| Max. Negotiated Rate |
$44.00 |
| Rate for Payer: Aetna Commercial |
$41.80
|
| Rate for Payer: Aetna Medicare |
$39.60
|
| Rate for Payer: BCBS MT CHIP |
$39.60
|
| Rate for Payer: BCBS MT Closed Plan Network |
$41.80
|
| Rate for Payer: BCBS MT HealthLink |
$39.60
|
| Rate for Payer: BCBS MT Medicare |
$39.60
|
| Rate for Payer: BCBS MT POS |
$41.80
|
| Rate for Payer: BCBS MT Traditional |
$44.00
|
| Rate for Payer: Cash Price |
$39.60
|
| Rate for Payer: Cigna Commercial |
$41.80
|
| Rate for Payer: Cigna Medicare |
$39.60
|
| Rate for Payer: Medicaid All Medicaid |
$40.48
|
| Rate for Payer: Medicare All Medicare |
$30.80
|
| Rate for Payer: Monida Allegiance |
$41.80
|
| Rate for Payer: Monida First Choice Health |
$42.68
|
| Rate for Payer: Monida Montana Health Co-op |
$41.80
|
| Rate for Payer: Monida PacificSource |
$41.80
|
|
|
SODIUM, RANDOM URINE (013326)
|
Facility
|
IP
|
$57.00
|
|
|
Service Code
|
CPT 84300
|
| Hospital Charge Code |
4084300
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$39.90 |
| Max. Negotiated Rate |
$57.00 |
| Rate for Payer: Aetna Commercial |
$54.15
|
| Rate for Payer: Aetna Medicare |
$51.30
|
| Rate for Payer: BCBS MT CHIP |
$51.30
|
| Rate for Payer: BCBS MT Closed Plan Network |
$54.15
|
| Rate for Payer: BCBS MT HealthLink |
$51.30
|
| Rate for Payer: BCBS MT Medicare |
$51.30
|
| Rate for Payer: BCBS MT POS |
$54.15
|
| Rate for Payer: BCBS MT Traditional |
$57.00
|
| Rate for Payer: Cash Price |
$51.30
|
| Rate for Payer: Cigna Commercial |
$54.15
|
| Rate for Payer: Cigna Medicare |
$51.30
|
| Rate for Payer: Medicaid All Medicaid |
$52.44
|
| Rate for Payer: Medicare All Medicare |
$39.90
|
| Rate for Payer: Monida Allegiance |
$54.15
|
| Rate for Payer: Monida First Choice Health |
$55.29
|
| Rate for Payer: Monida Montana Health Co-op |
$54.15
|
| Rate for Payer: Monida PacificSource |
$54.15
|
|
|
SODIUM, RANDOM URINE (013326)
|
Facility
|
OP
|
$57.00
|
|
|
Service Code
|
CPT 84300
|
| Hospital Charge Code |
4084300
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$39.90 |
| Max. Negotiated Rate |
$57.00 |
| Rate for Payer: Aetna Commercial |
$54.15
|
| Rate for Payer: Aetna Medicare |
$51.30
|
| Rate for Payer: BCBS MT CHIP |
$51.30
|
| Rate for Payer: BCBS MT Closed Plan Network |
$54.15
|
| Rate for Payer: BCBS MT HealthLink |
$51.30
|
| Rate for Payer: BCBS MT Medicare |
$51.30
|
| Rate for Payer: BCBS MT POS |
$54.15
|
| Rate for Payer: BCBS MT Traditional |
$57.00
|
| Rate for Payer: Cash Price |
$51.30
|
| Rate for Payer: Cigna Commercial |
$54.15
|
| Rate for Payer: Cigna Medicare |
$51.30
|
| Rate for Payer: Medicaid All Medicaid |
$52.44
|
| Rate for Payer: Medicare All Medicare |
$39.90
|
| Rate for Payer: Monida Allegiance |
$54.15
|
| Rate for Payer: Monida First Choice Health |
$55.29
|
| Rate for Payer: Monida Montana Health Co-op |
$54.15
|
| Rate for Payer: Monida PacificSource |
$54.15
|
|
|
SOLIFENACIN SUCC TAB [10 MG] NF
|
Facility
|
OP
|
$42.00
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
3007556
|
|
Hospital Revenue Code
|
250
|
| 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
|
|
|
SOLIFENACIN SUCC TAB [10 MG] NF
|
Facility
|
IP
|
$42.00
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
3007556
|
|
Hospital Revenue Code
|
250
|
| 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
|
|
