|
TORSEMIDE TAB [20 MG]
|
Facility
|
IP
|
$8.00
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
3000456
|
|
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
|
|
|
TORSEMIDE TAB [20 MG]
|
Facility
|
OP
|
$8.00
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
3000456
|
|
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
|
|
|
TOTAL AND FREE T3
|
Facility
|
OP
|
$130.00
|
|
|
Service Code
|
CPT 84480
|
| Hospital Charge Code |
4087986
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$91.00 |
| Max. Negotiated Rate |
$130.00 |
| Rate for Payer: Aetna Commercial |
$123.50
|
| Rate for Payer: Aetna Medicare |
$117.00
|
| Rate for Payer: BCBS MT CHIP |
$117.00
|
| Rate for Payer: BCBS MT Closed Plan Network |
$123.50
|
| Rate for Payer: BCBS MT HealthLink |
$117.00
|
| Rate for Payer: BCBS MT Medicare |
$117.00
|
| Rate for Payer: BCBS MT POS |
$123.50
|
| Rate for Payer: BCBS MT Traditional |
$130.00
|
| Rate for Payer: Cash Price |
$117.00
|
| Rate for Payer: Cigna Commercial |
$123.50
|
| Rate for Payer: Cigna Medicare |
$117.00
|
| Rate for Payer: Medicaid All Medicaid |
$119.60
|
| Rate for Payer: Medicare All Medicare |
$91.00
|
| Rate for Payer: Monida Allegiance |
$123.50
|
| Rate for Payer: Monida First Choice Health |
$126.10
|
| Rate for Payer: Monida Montana Health Co-op |
$123.50
|
| Rate for Payer: Monida PacificSource |
$123.50
|
|
|
TOTAL AND FREE T3
|
Facility
|
IP
|
$130.00
|
|
|
Service Code
|
CPT 84480
|
| Hospital Charge Code |
4087986
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$91.00 |
| Max. Negotiated Rate |
$130.00 |
| Rate for Payer: Aetna Commercial |
$123.50
|
| Rate for Payer: Aetna Medicare |
$117.00
|
| Rate for Payer: BCBS MT CHIP |
$117.00
|
| Rate for Payer: BCBS MT Closed Plan Network |
$123.50
|
| Rate for Payer: BCBS MT HealthLink |
$117.00
|
| Rate for Payer: BCBS MT Medicare |
$117.00
|
| Rate for Payer: BCBS MT POS |
$123.50
|
| Rate for Payer: BCBS MT Traditional |
$130.00
|
| Rate for Payer: Cash Price |
$117.00
|
| Rate for Payer: Cigna Commercial |
$123.50
|
| Rate for Payer: Cigna Medicare |
$117.00
|
| Rate for Payer: Medicaid All Medicaid |
$119.60
|
| Rate for Payer: Medicare All Medicare |
$91.00
|
| Rate for Payer: Monida Allegiance |
$123.50
|
| Rate for Payer: Monida First Choice Health |
$126.10
|
| Rate for Payer: Monida Montana Health Co-op |
$123.50
|
| Rate for Payer: Monida PacificSource |
$123.50
|
|
|
TOTAL AND FREE TESTOSTERONE (0070109)
|
Facility
|
IP
|
$155.00
|
|
|
Service Code
|
CPT 84402
|
| Hospital Charge Code |
4087988
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$108.50 |
| Max. Negotiated Rate |
$155.00 |
| Rate for Payer: Aetna Commercial |
$147.25
|
| Rate for Payer: Aetna Medicare |
$139.50
|
| Rate for Payer: BCBS MT CHIP |
$139.50
|
| Rate for Payer: BCBS MT Closed Plan Network |
$147.25
|
| Rate for Payer: BCBS MT HealthLink |
$139.50
|
| Rate for Payer: BCBS MT Medicare |
$139.50
|
| Rate for Payer: BCBS MT POS |
$147.25
|
| Rate for Payer: BCBS MT Traditional |
$155.00
|
| Rate for Payer: Cash Price |
$139.50
|
| Rate for Payer: Cigna Commercial |
$147.25
|
| Rate for Payer: Cigna Medicare |
$139.50
|
| Rate for Payer: Medicaid All Medicaid |
$142.60
|
| Rate for Payer: Medicare All Medicare |
$108.50
|
| Rate for Payer: Monida Allegiance |
$147.25
|
| Rate for Payer: Monida First Choice Health |
$150.35
|
| Rate for Payer: Monida Montana Health Co-op |
$147.25
|
| Rate for Payer: Monida PacificSource |
$147.25
|
|
|
TOTAL AND FREE TESTOSTERONE (0070109)
|
Facility
|
OP
|
$155.00
|
|
|
Service Code
|
CPT 84402
|
| Hospital Charge Code |
4087988
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$108.50 |
| Max. Negotiated Rate |
$155.00 |
| Rate for Payer: Aetna Commercial |
$147.25
|
| Rate for Payer: Aetna Medicare |
$139.50
|
| Rate for Payer: BCBS MT CHIP |
$139.50
|
| Rate for Payer: BCBS MT Closed Plan Network |
$147.25
|
| Rate for Payer: BCBS MT HealthLink |
$139.50
|
| Rate for Payer: BCBS MT Medicare |
$139.50
|
| Rate for Payer: BCBS MT POS |
$147.25
|
| Rate for Payer: BCBS MT Traditional |
$155.00
|
| Rate for Payer: Cash Price |
$139.50
|
| Rate for Payer: Cigna Commercial |
$147.25
|
| Rate for Payer: Cigna Medicare |
$139.50
|
| Rate for Payer: Medicaid All Medicaid |
$142.60
|
| Rate for Payer: Medicare All Medicare |
$108.50
|
| Rate for Payer: Monida Allegiance |
$147.25
|
| Rate for Payer: Monida First Choice Health |
$150.35
|
| Rate for Payer: Monida Montana Health Co-op |
$147.25
|
| Rate for Payer: Monida PacificSource |
$147.25
|
|
|
TOTAL AND FREE TESTOSTERONE FEMALE
|
Facility
|
OP
|
$120.00
|
|
|
Service Code
|
CPT 84403
|
| Hospital Charge Code |
4088132
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$84.00 |
| Max. Negotiated Rate |
$120.00 |
| Rate for Payer: Aetna Commercial |
$114.00
|
| Rate for Payer: Aetna Medicare |
$108.00
|
| Rate for Payer: BCBS MT CHIP |
$108.00
|
| Rate for Payer: BCBS MT Closed Plan Network |
$114.00
|
| Rate for Payer: BCBS MT HealthLink |
$108.00
|
| Rate for Payer: BCBS MT Medicare |
$108.00
|
| Rate for Payer: BCBS MT POS |
$114.00
|
| Rate for Payer: BCBS MT Traditional |
$120.00
|
| Rate for Payer: Cash Price |
$108.00
|
| Rate for Payer: Cigna Commercial |
$114.00
|
| Rate for Payer: Cigna Medicare |
$108.00
|
| Rate for Payer: Medicaid All Medicaid |
$110.40
|
| Rate for Payer: Medicare All Medicare |
$84.00
|
| Rate for Payer: Monida Allegiance |
$114.00
|
| Rate for Payer: Monida First Choice Health |
$116.40
|
| Rate for Payer: Monida Montana Health Co-op |
$114.00
|
| Rate for Payer: Monida PacificSource |
$114.00
|
|
|
TOTAL AND FREE TESTOSTERONE FEMALE
|
Facility
|
IP
|
$120.00
|
|
|
Service Code
|
CPT 84403
|
| Hospital Charge Code |
4088132
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$84.00 |
| Max. Negotiated Rate |
$120.00 |
| Rate for Payer: Aetna Commercial |
$114.00
|
| Rate for Payer: Aetna Medicare |
$108.00
|
| Rate for Payer: BCBS MT CHIP |
$108.00
|
| Rate for Payer: BCBS MT Closed Plan Network |
$114.00
|
| Rate for Payer: BCBS MT HealthLink |
$108.00
|
| Rate for Payer: BCBS MT Medicare |
$108.00
|
| Rate for Payer: BCBS MT POS |
$114.00
|
| Rate for Payer: BCBS MT Traditional |
$120.00
|
| Rate for Payer: Cash Price |
$108.00
|
| Rate for Payer: Cigna Commercial |
$114.00
|
| Rate for Payer: Cigna Medicare |
$108.00
|
| Rate for Payer: Medicaid All Medicaid |
$110.40
|
| Rate for Payer: Medicare All Medicare |
$84.00
|
| Rate for Payer: Monida Allegiance |
$114.00
|
| Rate for Payer: Monida First Choice Health |
$116.40
|
| Rate for Payer: Monida Montana Health Co-op |
$114.00
|
| Rate for Payer: Monida PacificSource |
$114.00
|
|
|
.TOTAL IRON-BINDING CAPACITY
|
Facility
|
OP
|
$58.00
|
|
|
Service Code
|
CPT 83550
|
| Hospital Charge Code |
4083550
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$40.60 |
| Max. Negotiated Rate |
$58.00 |
| Rate for Payer: Aetna Commercial |
$55.10
|
| Rate for Payer: Aetna Medicare |
$52.20
|
| Rate for Payer: BCBS MT CHIP |
$52.20
|
| Rate for Payer: BCBS MT Closed Plan Network |
$55.10
|
| Rate for Payer: BCBS MT HealthLink |
$52.20
|
| Rate for Payer: BCBS MT Medicare |
$52.20
|
| Rate for Payer: BCBS MT POS |
$55.10
|
| Rate for Payer: BCBS MT Traditional |
$58.00
|
| Rate for Payer: Cash Price |
$52.20
|
| Rate for Payer: Cigna Commercial |
$55.10
|
| Rate for Payer: Cigna Medicare |
$52.20
|
| Rate for Payer: Medicaid All Medicaid |
$53.36
|
| Rate for Payer: Medicare All Medicare |
$40.60
|
| Rate for Payer: Monida Allegiance |
$55.10
|
| Rate for Payer: Monida First Choice Health |
$56.26
|
| Rate for Payer: Monida Montana Health Co-op |
$55.10
|
| Rate for Payer: Monida PacificSource |
$55.10
|
|
|
.TOTAL IRON-BINDING CAPACITY
|
Facility
|
IP
|
$58.00
|
|
|
Service Code
|
CPT 83550
|
| Hospital Charge Code |
4083550
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$40.60 |
| Max. Negotiated Rate |
$58.00 |
| Rate for Payer: Aetna Commercial |
$55.10
|
| Rate for Payer: Aetna Medicare |
$52.20
|
| Rate for Payer: BCBS MT CHIP |
$52.20
|
| Rate for Payer: BCBS MT Closed Plan Network |
$55.10
|
| Rate for Payer: BCBS MT HealthLink |
$52.20
|
| Rate for Payer: BCBS MT Medicare |
$52.20
|
| Rate for Payer: BCBS MT POS |
$55.10
|
| Rate for Payer: BCBS MT Traditional |
$58.00
|
| Rate for Payer: Cash Price |
$52.20
|
| Rate for Payer: Cigna Commercial |
$55.10
|
| Rate for Payer: Cigna Medicare |
$52.20
|
| Rate for Payer: Medicaid All Medicaid |
$53.36
|
| Rate for Payer: Medicare All Medicare |
$40.60
|
| Rate for Payer: Monida Allegiance |
$55.10
|
| Rate for Payer: Monida First Choice Health |
$56.26
|
| Rate for Payer: Monida Montana Health Co-op |
$55.10
|
| Rate for Payer: Monida PacificSource |
$55.10
|
|
|
TOTAL PROTEIN/ALBUMIN CALIBRAT
|
Facility
|
OP
|
$26.78
|
|
| Hospital Charge Code |
90195013
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$18.75 |
| Max. Negotiated Rate |
$26.78 |
| Rate for Payer: Aetna Commercial |
$25.44
|
| Rate for Payer: Aetna Medicare |
$24.10
|
| Rate for Payer: BCBS MT CHIP |
$24.10
|
| Rate for Payer: BCBS MT Closed Plan Network |
$25.44
|
| Rate for Payer: BCBS MT HealthLink |
$24.10
|
| Rate for Payer: BCBS MT Medicare |
$24.10
|
| Rate for Payer: BCBS MT POS |
$25.44
|
| Rate for Payer: BCBS MT Traditional |
$26.78
|
| Rate for Payer: Cash Price |
$24.10
|
| Rate for Payer: Cigna Commercial |
$25.44
|
| Rate for Payer: Cigna Medicare |
$24.10
|
| Rate for Payer: Medicaid All Medicaid |
$24.64
|
| Rate for Payer: Medicare All Medicare |
$18.75
|
| Rate for Payer: Monida Allegiance |
$25.44
|
| Rate for Payer: Monida First Choice Health |
$25.98
|
| Rate for Payer: Monida Montana Health Co-op |
$25.44
|
| Rate for Payer: Monida PacificSource |
$25.44
|
|
|
TOTAL PROTEIN/ALBUMIN CALIBRAT
|
Facility
|
IP
|
$26.78
|
|
| Hospital Charge Code |
90195013
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$18.75 |
| Max. Negotiated Rate |
$26.78 |
| Rate for Payer: Aetna Commercial |
$25.44
|
| Rate for Payer: Aetna Medicare |
$24.10
|
| Rate for Payer: BCBS MT CHIP |
$24.10
|
| Rate for Payer: BCBS MT Closed Plan Network |
$25.44
|
| Rate for Payer: BCBS MT HealthLink |
$24.10
|
| Rate for Payer: BCBS MT Medicare |
$24.10
|
| Rate for Payer: BCBS MT POS |
$25.44
|
| Rate for Payer: BCBS MT Traditional |
$26.78
|
| Rate for Payer: Cash Price |
$24.10
|
| Rate for Payer: Cigna Commercial |
$25.44
|
| Rate for Payer: Cigna Medicare |
$24.10
|
| Rate for Payer: Medicaid All Medicaid |
$24.64
|
| Rate for Payer: Medicare All Medicare |
$18.75
|
| Rate for Payer: Monida Allegiance |
$25.44
|
| Rate for Payer: Monida First Choice Health |
$25.98
|
| Rate for Payer: Monida Montana Health Co-op |
$25.44
|
| Rate for Payer: Monida PacificSource |
$25.44
|
|
|
.TOTAL PROTEIN, URINE
|
Facility
|
IP
|
$55.00
|
|
|
Service Code
|
CPT 84156
|
| Hospital Charge Code |
4084156
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$38.50 |
| Max. Negotiated Rate |
$55.00 |
| Rate for Payer: Aetna Commercial |
$52.25
|
| Rate for Payer: Aetna Medicare |
$49.50
|
| Rate for Payer: BCBS MT CHIP |
$49.50
|
| Rate for Payer: BCBS MT Closed Plan Network |
$52.25
|
| Rate for Payer: BCBS MT HealthLink |
$49.50
|
| Rate for Payer: BCBS MT Medicare |
$49.50
|
| Rate for Payer: BCBS MT POS |
$52.25
|
| Rate for Payer: BCBS MT Traditional |
$55.00
|
| Rate for Payer: Cash Price |
$49.50
|
| Rate for Payer: Cigna Commercial |
$52.25
|
| Rate for Payer: Cigna Medicare |
$49.50
|
| Rate for Payer: Medicaid All Medicaid |
$50.60
|
| Rate for Payer: Medicare All Medicare |
$38.50
|
| Rate for Payer: Monida Allegiance |
$52.25
|
| Rate for Payer: Monida First Choice Health |
$53.35
|
| Rate for Payer: Monida Montana Health Co-op |
$52.25
|
| Rate for Payer: Monida PacificSource |
$52.25
|
|
|
.TOTAL PROTEIN, URINE
|
Facility
|
OP
|
$55.00
|
|
|
Service Code
|
CPT 84156
|
| Hospital Charge Code |
4084156
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$38.50 |
| Max. Negotiated Rate |
$55.00 |
| Rate for Payer: Aetna Commercial |
$52.25
|
| Rate for Payer: Aetna Medicare |
$49.50
|
| Rate for Payer: BCBS MT CHIP |
$49.50
|
| Rate for Payer: BCBS MT Closed Plan Network |
$52.25
|
| Rate for Payer: BCBS MT HealthLink |
$49.50
|
| Rate for Payer: BCBS MT Medicare |
$49.50
|
| Rate for Payer: BCBS MT POS |
$52.25
|
| Rate for Payer: BCBS MT Traditional |
$55.00
|
| Rate for Payer: Cash Price |
$49.50
|
| Rate for Payer: Cigna Commercial |
$52.25
|
| Rate for Payer: Cigna Medicare |
$49.50
|
| Rate for Payer: Medicaid All Medicaid |
$50.60
|
| Rate for Payer: Medicare All Medicare |
$38.50
|
| Rate for Payer: Monida Allegiance |
$52.25
|
| Rate for Payer: Monida First Choice Health |
$53.35
|
| Rate for Payer: Monida Montana Health Co-op |
$52.25
|
| Rate for Payer: Monida PacificSource |
$52.25
|
|
|
TOURNIQUET (LAB ONLY)
|
Facility
|
IP
|
$29.82
|
|
| Hospital Charge Code |
90195381
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$20.87 |
| Max. Negotiated Rate |
$29.82 |
| Rate for Payer: Aetna Commercial |
$28.33
|
| Rate for Payer: Aetna Medicare |
$26.84
|
| Rate for Payer: BCBS MT CHIP |
$26.84
|
| Rate for Payer: BCBS MT Closed Plan Network |
$28.33
|
| Rate for Payer: BCBS MT HealthLink |
$26.84
|
| Rate for Payer: BCBS MT Medicare |
$26.84
|
| Rate for Payer: BCBS MT POS |
$28.33
|
| Rate for Payer: BCBS MT Traditional |
$29.82
|
| Rate for Payer: Cash Price |
$26.84
|
| Rate for Payer: Cigna Commercial |
$28.33
|
| Rate for Payer: Cigna Medicare |
$26.84
|
| Rate for Payer: Medicaid All Medicaid |
$27.43
|
| Rate for Payer: Medicare All Medicare |
$20.87
|
| Rate for Payer: Monida Allegiance |
$28.33
|
| Rate for Payer: Monida First Choice Health |
$28.93
|
| Rate for Payer: Monida Montana Health Co-op |
$28.33
|
| Rate for Payer: Monida PacificSource |
$28.33
|
|
|
TOURNIQUET (LAB ONLY)
|
Facility
|
OP
|
$29.82
|
|
| Hospital Charge Code |
90195381
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$20.87 |
| Max. Negotiated Rate |
$29.82 |
| Rate for Payer: Aetna Commercial |
$28.33
|
| Rate for Payer: Aetna Medicare |
$26.84
|
| Rate for Payer: BCBS MT CHIP |
$26.84
|
| Rate for Payer: BCBS MT Closed Plan Network |
$28.33
|
| Rate for Payer: BCBS MT HealthLink |
$26.84
|
| Rate for Payer: BCBS MT Medicare |
$26.84
|
| Rate for Payer: BCBS MT POS |
$28.33
|
| Rate for Payer: BCBS MT Traditional |
$29.82
|
| Rate for Payer: Cash Price |
$26.84
|
| Rate for Payer: Cigna Commercial |
$28.33
|
| Rate for Payer: Cigna Medicare |
$26.84
|
| Rate for Payer: Medicaid All Medicaid |
$27.43
|
| Rate for Payer: Medicare All Medicare |
$20.87
|
| Rate for Payer: Monida Allegiance |
$28.33
|
| Rate for Payer: Monida First Choice Health |
$28.93
|
| Rate for Payer: Monida Montana Health Co-op |
$28.33
|
| Rate for Payer: Monida PacificSource |
$28.33
|
|
|
TOXOPLASMA GONDII IGG IGM AB
|
Facility
|
IP
|
$100.00
|
|
|
Service Code
|
CPT 86777
|
| Hospital Charge Code |
4087971
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$70.00 |
| Max. Negotiated Rate |
$100.00 |
| Rate for Payer: Aetna Commercial |
$95.00
|
| Rate for Payer: Aetna Medicare |
$90.00
|
| Rate for Payer: BCBS MT CHIP |
$90.00
|
| Rate for Payer: BCBS MT Closed Plan Network |
$95.00
|
| Rate for Payer: BCBS MT HealthLink |
$90.00
|
| Rate for Payer: BCBS MT Medicare |
$90.00
|
| Rate for Payer: BCBS MT POS |
$95.00
|
| Rate for Payer: BCBS MT Traditional |
$100.00
|
| Rate for Payer: Cash Price |
$90.00
|
| Rate for Payer: Cigna Commercial |
$95.00
|
| Rate for Payer: Cigna Medicare |
$90.00
|
| Rate for Payer: Medicaid All Medicaid |
$92.00
|
| Rate for Payer: Medicare All Medicare |
$70.00
|
| Rate for Payer: Monida Allegiance |
$95.00
|
| Rate for Payer: Monida First Choice Health |
$97.00
|
| Rate for Payer: Monida Montana Health Co-op |
$95.00
|
| Rate for Payer: Monida PacificSource |
$95.00
|
|
|
TOXOPLASMA GONDII IGG IGM AB
|
Facility
|
OP
|
$100.00
|
|
|
Service Code
|
CPT 86777
|
| Hospital Charge Code |
4087971
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$70.00 |
| Max. Negotiated Rate |
$100.00 |
| Rate for Payer: Aetna Commercial |
$95.00
|
| Rate for Payer: Aetna Medicare |
$90.00
|
| Rate for Payer: BCBS MT CHIP |
$90.00
|
| Rate for Payer: BCBS MT Closed Plan Network |
$95.00
|
| Rate for Payer: BCBS MT HealthLink |
$90.00
|
| Rate for Payer: BCBS MT Medicare |
$90.00
|
| Rate for Payer: BCBS MT POS |
$95.00
|
| Rate for Payer: BCBS MT Traditional |
$100.00
|
| Rate for Payer: Cash Price |
$90.00
|
| Rate for Payer: Cigna Commercial |
$95.00
|
| Rate for Payer: Cigna Medicare |
$90.00
|
| Rate for Payer: Medicaid All Medicaid |
$92.00
|
| Rate for Payer: Medicare All Medicare |
$70.00
|
| Rate for Payer: Monida Allegiance |
$95.00
|
| Rate for Payer: Monida First Choice Health |
$97.00
|
| Rate for Payer: Monida Montana Health Co-op |
$95.00
|
| Rate for Payer: Monida PacificSource |
$95.00
|
|
|
T PALLIDUM SCREENING CASCADE (082345)
|
Facility
|
OP
|
$69.00
|
|
|
Service Code
|
CPT 86780
|
| Hospital Charge Code |
4086780
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$48.30 |
| Max. Negotiated Rate |
$69.00 |
| Rate for Payer: Aetna Commercial |
$65.55
|
| Rate for Payer: Aetna Medicare |
$62.10
|
| Rate for Payer: BCBS MT CHIP |
$62.10
|
| Rate for Payer: BCBS MT Closed Plan Network |
$65.55
|
| Rate for Payer: BCBS MT HealthLink |
$62.10
|
| Rate for Payer: BCBS MT Medicare |
$62.10
|
| Rate for Payer: BCBS MT POS |
$65.55
|
| Rate for Payer: BCBS MT Traditional |
$69.00
|
| Rate for Payer: Cash Price |
$62.10
|
| Rate for Payer: Cigna Commercial |
$65.55
|
| Rate for Payer: Cigna Medicare |
$62.10
|
| Rate for Payer: Medicaid All Medicaid |
$63.48
|
| Rate for Payer: Medicare All Medicare |
$48.30
|
| Rate for Payer: Monida Allegiance |
$65.55
|
| Rate for Payer: Monida First Choice Health |
$66.93
|
| Rate for Payer: Monida Montana Health Co-op |
$65.55
|
| Rate for Payer: Monida PacificSource |
$65.55
|
|
|
T PALLIDUM SCREENING CASCADE (082345)
|
Facility
|
IP
|
$69.00
|
|
|
Service Code
|
CPT 86780
|
| Hospital Charge Code |
4086780
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$48.30 |
| Max. Negotiated Rate |
$69.00 |
| Rate for Payer: Aetna Commercial |
$65.55
|
| Rate for Payer: Aetna Medicare |
$62.10
|
| Rate for Payer: BCBS MT CHIP |
$62.10
|
| Rate for Payer: BCBS MT Closed Plan Network |
$65.55
|
| Rate for Payer: BCBS MT HealthLink |
$62.10
|
| Rate for Payer: BCBS MT Medicare |
$62.10
|
| Rate for Payer: BCBS MT POS |
$65.55
|
| Rate for Payer: BCBS MT Traditional |
$69.00
|
| Rate for Payer: Cash Price |
$62.10
|
| Rate for Payer: Cigna Commercial |
$65.55
|
| Rate for Payer: Cigna Medicare |
$62.10
|
| Rate for Payer: Medicaid All Medicaid |
$63.48
|
| Rate for Payer: Medicare All Medicare |
$48.30
|
| Rate for Payer: Monida Allegiance |
$65.55
|
| Rate for Payer: Monida First Choice Health |
$66.93
|
| Rate for Payer: Monida Montana Health Co-op |
$65.55
|
| Rate for Payer: Monida PacificSource |
$65.55
|
|
|
TRAMADOL TAB [50 MG]
|
Facility
|
OP
|
$8.00
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
3000457
|
|
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
|
|
|
TRAMADOL TAB [50 MG]
|
Facility
|
IP
|
$8.00
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
3000457
|
|
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
|
|
|
TRANEXAMIC ACID 100MG/ML 10ML VIAL
|
Facility
|
IP
|
$24.00
|
|
|
Service Code
|
HCPCS J3291
|
| Hospital Charge Code |
3000458
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$16.80 |
| Max. Negotiated Rate |
$24.00 |
| Rate for Payer: Aetna Commercial |
$22.80
|
| Rate for Payer: Aetna Medicare |
$21.60
|
| Rate for Payer: BCBS MT CHIP |
$21.60
|
| Rate for Payer: BCBS MT Closed Plan Network |
$22.80
|
| Rate for Payer: BCBS MT HealthLink |
$21.60
|
| Rate for Payer: BCBS MT Medicare |
$21.60
|
| Rate for Payer: BCBS MT POS |
$22.80
|
| Rate for Payer: BCBS MT Traditional |
$24.00
|
| Rate for Payer: Cash Price |
$21.60
|
| Rate for Payer: Cigna Commercial |
$22.80
|
| Rate for Payer: Cigna Medicare |
$21.60
|
| Rate for Payer: Medicaid All Medicaid |
$22.08
|
| Rate for Payer: Medicare All Medicare |
$16.80
|
| Rate for Payer: Monida Allegiance |
$22.80
|
| Rate for Payer: Monida First Choice Health |
$23.28
|
| Rate for Payer: Monida Montana Health Co-op |
$22.80
|
| Rate for Payer: Monida PacificSource |
$22.80
|
|
|
TRANEXAMIC ACID 100MG/ML 10ML VIAL
|
Facility
|
OP
|
$24.00
|
|
|
Service Code
|
HCPCS J3291
|
| Hospital Charge Code |
3000458
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$16.80 |
| Max. Negotiated Rate |
$24.00 |
| Rate for Payer: Aetna Commercial |
$22.80
|
| Rate for Payer: Aetna Medicare |
$21.60
|
| Rate for Payer: BCBS MT CHIP |
$21.60
|
| Rate for Payer: BCBS MT Closed Plan Network |
$22.80
|
| Rate for Payer: BCBS MT HealthLink |
$21.60
|
| Rate for Payer: BCBS MT Medicare |
$21.60
|
| Rate for Payer: BCBS MT POS |
$22.80
|
| Rate for Payer: BCBS MT Traditional |
$24.00
|
| Rate for Payer: Cash Price |
$21.60
|
| Rate for Payer: Cigna Commercial |
$22.80
|
| Rate for Payer: Cigna Medicare |
$21.60
|
| Rate for Payer: Medicaid All Medicaid |
$22.08
|
| Rate for Payer: Medicare All Medicare |
$16.80
|
| Rate for Payer: Monida Allegiance |
$22.80
|
| Rate for Payer: Monida First Choice Health |
$23.28
|
| Rate for Payer: Monida Montana Health Co-op |
$22.80
|
| Rate for Payer: Monida PacificSource |
$22.80
|
|
|
TRANSFER PACK THERAPEUTIC PHL
|
Facility
|
IP
|
$195.39
|
|
| Hospital Charge Code |
90195271
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$136.77 |
| Max. Negotiated Rate |
$195.39 |
| Rate for Payer: Aetna Commercial |
$185.62
|
| Rate for Payer: Aetna Medicare |
$175.85
|
| Rate for Payer: BCBS MT CHIP |
$175.85
|
| Rate for Payer: BCBS MT Closed Plan Network |
$185.62
|
| Rate for Payer: BCBS MT HealthLink |
$175.85
|
| Rate for Payer: BCBS MT Medicare |
$175.85
|
| Rate for Payer: BCBS MT POS |
$185.62
|
| Rate for Payer: BCBS MT Traditional |
$195.39
|
| Rate for Payer: Cash Price |
$175.85
|
| Rate for Payer: Cigna Commercial |
$185.62
|
| Rate for Payer: Cigna Medicare |
$175.85
|
| Rate for Payer: Medicaid All Medicaid |
$179.76
|
| Rate for Payer: Medicare All Medicare |
$136.77
|
| Rate for Payer: Monida Allegiance |
$185.62
|
| Rate for Payer: Monida First Choice Health |
$189.53
|
| Rate for Payer: Monida Montana Health Co-op |
$185.62
|
| Rate for Payer: Monida PacificSource |
$185.62
|
|
