|
TRANSFER PACK THERAPEUTIC PHL
|
Facility
|
OP
|
$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
|
|
|
TRANSFERRIN (004937)
|
Facility
|
IP
|
$91.00
|
|
|
Service Code
|
CPT 84466
|
| Hospital Charge Code |
4084466
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$63.70 |
| Max. Negotiated Rate |
$91.00 |
| Rate for Payer: Aetna Commercial |
$86.45
|
| Rate for Payer: Aetna Medicare |
$81.90
|
| Rate for Payer: BCBS MT CHIP |
$81.90
|
| Rate for Payer: BCBS MT Closed Plan Network |
$86.45
|
| Rate for Payer: BCBS MT HealthLink |
$81.90
|
| Rate for Payer: BCBS MT Medicare |
$81.90
|
| Rate for Payer: BCBS MT POS |
$86.45
|
| Rate for Payer: BCBS MT Traditional |
$91.00
|
| Rate for Payer: Cash Price |
$81.90
|
| Rate for Payer: Cigna Commercial |
$86.45
|
| Rate for Payer: Cigna Medicare |
$81.90
|
| Rate for Payer: Medicaid All Medicaid |
$83.72
|
| Rate for Payer: Medicare All Medicare |
$63.70
|
| Rate for Payer: Monida Allegiance |
$86.45
|
| Rate for Payer: Monida First Choice Health |
$88.27
|
| Rate for Payer: Monida Montana Health Co-op |
$86.45
|
| Rate for Payer: Monida PacificSource |
$86.45
|
|
|
TRANSFERRIN (004937)
|
Facility
|
OP
|
$91.00
|
|
|
Service Code
|
CPT 84466
|
| Hospital Charge Code |
4084466
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$63.70 |
| Max. Negotiated Rate |
$91.00 |
| Rate for Payer: Aetna Commercial |
$86.45
|
| Rate for Payer: Aetna Medicare |
$81.90
|
| Rate for Payer: BCBS MT CHIP |
$81.90
|
| Rate for Payer: BCBS MT Closed Plan Network |
$86.45
|
| Rate for Payer: BCBS MT HealthLink |
$81.90
|
| Rate for Payer: BCBS MT Medicare |
$81.90
|
| Rate for Payer: BCBS MT POS |
$86.45
|
| Rate for Payer: BCBS MT Traditional |
$91.00
|
| Rate for Payer: Cash Price |
$81.90
|
| Rate for Payer: Cigna Commercial |
$86.45
|
| Rate for Payer: Cigna Medicare |
$81.90
|
| Rate for Payer: Medicaid All Medicaid |
$83.72
|
| Rate for Payer: Medicare All Medicare |
$63.70
|
| Rate for Payer: Monida Allegiance |
$86.45
|
| Rate for Payer: Monida First Choice Health |
$88.27
|
| Rate for Payer: Monida Montana Health Co-op |
$86.45
|
| Rate for Payer: Monida PacificSource |
$86.45
|
|
|
TRANSITIONAL CARE MGMT HIGH ACUITY
|
Facility
|
OP
|
$746.00
|
|
|
Service Code
|
CPT 99496
|
| Hospital Charge Code |
8099496
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$522.20 |
| Max. Negotiated Rate |
$746.00 |
| Rate for Payer: Aetna Commercial |
$708.70
|
| Rate for Payer: Aetna Medicare |
$671.40
|
| Rate for Payer: BCBS MT CHIP |
$671.40
|
| Rate for Payer: BCBS MT Closed Plan Network |
$708.70
|
| Rate for Payer: BCBS MT HealthLink |
$671.40
|
| Rate for Payer: BCBS MT Medicare |
$671.40
|
| Rate for Payer: BCBS MT POS |
$708.70
|
| Rate for Payer: BCBS MT Traditional |
$746.00
|
| Rate for Payer: Cash Price |
$671.40
|
| Rate for Payer: Cigna Commercial |
$708.70
|
| Rate for Payer: Cigna Medicare |
$671.40
|
| Rate for Payer: Medicaid All Medicaid |
$686.32
|
| Rate for Payer: Medicare All Medicare |
$522.20
|
| Rate for Payer: Monida Allegiance |
$708.70
|
| Rate for Payer: Monida First Choice Health |
$723.62
|
| Rate for Payer: Monida Montana Health Co-op |
$708.70
|
| Rate for Payer: Monida PacificSource |
$708.70
|
|
|
TRANSITIONAL CARE MGMT HIGH ACUITY
|
Facility
|
IP
|
$746.00
|
|
|
Service Code
|
CPT 99496
|
| Hospital Charge Code |
8099496
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$522.20 |
| Max. Negotiated Rate |
$746.00 |
| Rate for Payer: Aetna Commercial |
$708.70
|
| Rate for Payer: Aetna Medicare |
$671.40
|
| Rate for Payer: BCBS MT CHIP |
$671.40
|
| Rate for Payer: BCBS MT Closed Plan Network |
$708.70
|
| Rate for Payer: BCBS MT HealthLink |
$671.40
|
| Rate for Payer: BCBS MT Medicare |
$671.40
|
| Rate for Payer: BCBS MT POS |
$708.70
|
| Rate for Payer: BCBS MT Traditional |
$746.00
|
| Rate for Payer: Cash Price |
$671.40
|
| Rate for Payer: Cigna Commercial |
$708.70
|
| Rate for Payer: Cigna Medicare |
$671.40
|
| Rate for Payer: Medicaid All Medicaid |
$686.32
|
| Rate for Payer: Medicare All Medicare |
$522.20
|
| Rate for Payer: Monida Allegiance |
$708.70
|
| Rate for Payer: Monida First Choice Health |
$723.62
|
| Rate for Payer: Monida Montana Health Co-op |
$708.70
|
| Rate for Payer: Monida PacificSource |
$708.70
|
|
|
TRANSITIONAL CARE MGMT MOD ACUITY
|
Facility
|
IP
|
$550.00
|
|
|
Service Code
|
CPT 99495
|
| Hospital Charge Code |
8099495
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$385.00 |
| Max. Negotiated Rate |
$550.00 |
| Rate for Payer: Aetna Commercial |
$522.50
|
| Rate for Payer: Aetna Medicare |
$495.00
|
| Rate for Payer: BCBS MT CHIP |
$495.00
|
| Rate for Payer: BCBS MT Closed Plan Network |
$522.50
|
| Rate for Payer: BCBS MT HealthLink |
$495.00
|
| Rate for Payer: BCBS MT Medicare |
$495.00
|
| Rate for Payer: BCBS MT POS |
$522.50
|
| Rate for Payer: BCBS MT Traditional |
$550.00
|
| Rate for Payer: Cash Price |
$495.00
|
| Rate for Payer: Cigna Commercial |
$522.50
|
| Rate for Payer: Cigna Medicare |
$495.00
|
| Rate for Payer: Medicaid All Medicaid |
$506.00
|
| Rate for Payer: Medicare All Medicare |
$385.00
|
| Rate for Payer: Monida Allegiance |
$522.50
|
| Rate for Payer: Monida First Choice Health |
$533.50
|
| Rate for Payer: Monida Montana Health Co-op |
$522.50
|
| Rate for Payer: Monida PacificSource |
$522.50
|
|
|
TRANSITIONAL CARE MGMT MOD ACUITY
|
Facility
|
OP
|
$550.00
|
|
|
Service Code
|
CPT 99495
|
| Hospital Charge Code |
8099495
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$385.00 |
| Max. Negotiated Rate |
$550.00 |
| Rate for Payer: Aetna Commercial |
$522.50
|
| Rate for Payer: Aetna Medicare |
$495.00
|
| Rate for Payer: BCBS MT CHIP |
$495.00
|
| Rate for Payer: BCBS MT Closed Plan Network |
$522.50
|
| Rate for Payer: BCBS MT HealthLink |
$495.00
|
| Rate for Payer: BCBS MT Medicare |
$495.00
|
| Rate for Payer: BCBS MT POS |
$522.50
|
| Rate for Payer: BCBS MT Traditional |
$550.00
|
| Rate for Payer: Cash Price |
$495.00
|
| Rate for Payer: Cigna Commercial |
$522.50
|
| Rate for Payer: Cigna Medicare |
$495.00
|
| Rate for Payer: Medicaid All Medicaid |
$506.00
|
| Rate for Payer: Medicare All Medicare |
$385.00
|
| Rate for Payer: Monida Allegiance |
$522.50
|
| Rate for Payer: Monida First Choice Health |
$533.50
|
| Rate for Payer: Monida Montana Health Co-op |
$522.50
|
| Rate for Payer: Monida PacificSource |
$522.50
|
|
|
TRAUMA ACTIVATION
|
Facility
|
IP
|
$3,936.00
|
|
|
Service Code
|
HCPCS G0390
|
| Hospital Charge Code |
1010110
|
|
Hospital Revenue Code
|
681
|
| Min. Negotiated Rate |
$2,755.20 |
| Max. Negotiated Rate |
$3,936.00 |
| Rate for Payer: Aetna Commercial |
$3,739.20
|
| Rate for Payer: Aetna Medicare |
$3,542.40
|
| Rate for Payer: BCBS MT CHIP |
$3,542.40
|
| Rate for Payer: BCBS MT Closed Plan Network |
$3,739.20
|
| Rate for Payer: BCBS MT HealthLink |
$3,542.40
|
| Rate for Payer: BCBS MT Medicare |
$3,542.40
|
| Rate for Payer: BCBS MT POS |
$3,739.20
|
| Rate for Payer: BCBS MT Traditional |
$3,936.00
|
| Rate for Payer: Cash Price |
$3,542.40
|
| Rate for Payer: Cigna Commercial |
$3,739.20
|
| Rate for Payer: Cigna Medicare |
$3,542.40
|
| Rate for Payer: Medicaid All Medicaid |
$3,621.12
|
| Rate for Payer: Medicare All Medicare |
$2,755.20
|
| Rate for Payer: Monida Allegiance |
$3,739.20
|
| Rate for Payer: Monida First Choice Health |
$3,817.92
|
| Rate for Payer: Monida Montana Health Co-op |
$3,739.20
|
| Rate for Payer: Monida PacificSource |
$3,739.20
|
|
|
TRAUMA ACTIVATION
|
Facility
|
OP
|
$3,936.00
|
|
|
Service Code
|
HCPCS G0390
|
| Hospital Charge Code |
1010110
|
|
Hospital Revenue Code
|
681
|
| Min. Negotiated Rate |
$2,755.20 |
| Max. Negotiated Rate |
$3,936.00 |
| Rate for Payer: Aetna Commercial |
$3,739.20
|
| Rate for Payer: Aetna Medicare |
$3,542.40
|
| Rate for Payer: BCBS MT CHIP |
$3,542.40
|
| Rate for Payer: BCBS MT Closed Plan Network |
$3,739.20
|
| Rate for Payer: BCBS MT HealthLink |
$3,542.40
|
| Rate for Payer: BCBS MT Medicare |
$3,542.40
|
| Rate for Payer: BCBS MT POS |
$3,739.20
|
| Rate for Payer: BCBS MT Traditional |
$3,936.00
|
| Rate for Payer: Cash Price |
$3,542.40
|
| Rate for Payer: Cigna Commercial |
$3,739.20
|
| Rate for Payer: Cigna Medicare |
$3,542.40
|
| Rate for Payer: Medicaid All Medicaid |
$3,621.12
|
| Rate for Payer: Medicare All Medicare |
$2,755.20
|
| Rate for Payer: Monida Allegiance |
$3,739.20
|
| Rate for Payer: Monida First Choice Health |
$3,817.92
|
| Rate for Payer: Monida Montana Health Co-op |
$3,739.20
|
| Rate for Payer: Monida PacificSource |
$3,739.20
|
|
|
TRAVOPROST 0.004% SOLUTION 2.5 ML -NF
|
Facility
|
OP
|
$525.65
|
|
| Hospital Charge Code |
3007248
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$367.95 |
| Max. Negotiated Rate |
$525.65 |
| Rate for Payer: Aetna Commercial |
$499.37
|
| Rate for Payer: Aetna Medicare |
$473.08
|
| Rate for Payer: BCBS MT CHIP |
$473.08
|
| Rate for Payer: BCBS MT Closed Plan Network |
$499.37
|
| Rate for Payer: BCBS MT HealthLink |
$473.08
|
| Rate for Payer: BCBS MT Medicare |
$473.08
|
| Rate for Payer: BCBS MT POS |
$499.37
|
| Rate for Payer: BCBS MT Traditional |
$525.65
|
| Rate for Payer: Cash Price |
$473.09
|
| Rate for Payer: Cigna Commercial |
$499.37
|
| Rate for Payer: Cigna Medicare |
$473.08
|
| Rate for Payer: Medicaid All Medicaid |
$483.60
|
| Rate for Payer: Medicare All Medicare |
$367.95
|
| Rate for Payer: Monida Allegiance |
$499.37
|
| Rate for Payer: Monida First Choice Health |
$509.88
|
| Rate for Payer: Monida Montana Health Co-op |
$499.37
|
| Rate for Payer: Monida PacificSource |
$499.37
|
|
|
TRAVOPROST 0.004% SOLUTION 2.5 ML -NF
|
Facility
|
IP
|
$525.65
|
|
| Hospital Charge Code |
3007248
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$367.95 |
| Max. Negotiated Rate |
$525.65 |
| Rate for Payer: Aetna Commercial |
$499.37
|
| Rate for Payer: Aetna Medicare |
$473.08
|
| Rate for Payer: BCBS MT CHIP |
$473.08
|
| Rate for Payer: BCBS MT Closed Plan Network |
$499.37
|
| Rate for Payer: BCBS MT HealthLink |
$473.08
|
| Rate for Payer: BCBS MT Medicare |
$473.08
|
| Rate for Payer: BCBS MT POS |
$499.37
|
| Rate for Payer: BCBS MT Traditional |
$525.65
|
| Rate for Payer: Cash Price |
$473.09
|
| Rate for Payer: Cigna Commercial |
$499.37
|
| Rate for Payer: Cigna Medicare |
$473.08
|
| Rate for Payer: Medicaid All Medicaid |
$483.60
|
| Rate for Payer: Medicare All Medicare |
$367.95
|
| Rate for Payer: Monida Allegiance |
$499.37
|
| Rate for Payer: Monida First Choice Health |
$509.88
|
| Rate for Payer: Monida Montana Health Co-op |
$499.37
|
| Rate for Payer: Monida PacificSource |
$499.37
|
|
|
TRAZODONE TAB [50 MG]
|
Facility
|
IP
|
$8.00
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
3000459
|
|
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
|
|
|
TRAZODONE TAB [50 MG]
|
Facility
|
OP
|
$8.00
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
3000459
|
|
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
|
|
|
TR COVID-19 VAC ADMIN SINGLE DOSE- 90480
|
Facility
|
IP
|
$69.00
|
|
|
Service Code
|
CPT 90480
|
| Hospital Charge Code |
590480
|
|
Hospital Revenue Code
|
771
|
| 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
|
|
|
TR COVID-19 VAC ADMIN SINGLE DOSE- 90480
|
Facility
|
OP
|
$69.00
|
|
|
Service Code
|
CPT 90480
|
| Hospital Charge Code |
590480
|
|
Hospital Revenue Code
|
771
|
| 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
|
|
|
TR DRAINAGE OF FINGER ABCESS
|
Facility
|
IP
|
$282.00
|
|
|
Service Code
|
CPT 26010
|
| Hospital Charge Code |
1026010
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$197.40 |
| Max. Negotiated Rate |
$282.00 |
| Rate for Payer: Aetna Commercial |
$267.90
|
| Rate for Payer: Aetna Medicare |
$253.80
|
| Rate for Payer: BCBS MT CHIP |
$253.80
|
| Rate for Payer: BCBS MT Closed Plan Network |
$267.90
|
| Rate for Payer: BCBS MT HealthLink |
$253.80
|
| Rate for Payer: BCBS MT Medicare |
$253.80
|
| Rate for Payer: BCBS MT POS |
$267.90
|
| Rate for Payer: BCBS MT Traditional |
$282.00
|
| Rate for Payer: Cash Price |
$253.80
|
| Rate for Payer: Cigna Commercial |
$267.90
|
| Rate for Payer: Cigna Medicare |
$253.80
|
| Rate for Payer: Medicaid All Medicaid |
$259.44
|
| Rate for Payer: Medicare All Medicare |
$197.40
|
| Rate for Payer: Monida Allegiance |
$267.90
|
| Rate for Payer: Monida First Choice Health |
$273.54
|
| Rate for Payer: Monida Montana Health Co-op |
$267.90
|
| Rate for Payer: Monida PacificSource |
$267.90
|
|
|
TR DRAINAGE OF FINGER ABCESS
|
Facility
|
OP
|
$282.00
|
|
|
Service Code
|
CPT 26010
|
| Hospital Charge Code |
1026010
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$197.40 |
| Max. Negotiated Rate |
$282.00 |
| Rate for Payer: Aetna Commercial |
$267.90
|
| Rate for Payer: Aetna Medicare |
$253.80
|
| Rate for Payer: BCBS MT CHIP |
$253.80
|
| Rate for Payer: BCBS MT Closed Plan Network |
$267.90
|
| Rate for Payer: BCBS MT HealthLink |
$253.80
|
| Rate for Payer: BCBS MT Medicare |
$253.80
|
| Rate for Payer: BCBS MT POS |
$267.90
|
| Rate for Payer: BCBS MT Traditional |
$282.00
|
| Rate for Payer: Cash Price |
$253.80
|
| Rate for Payer: Cigna Commercial |
$267.90
|
| Rate for Payer: Cigna Medicare |
$253.80
|
| Rate for Payer: Medicaid All Medicaid |
$259.44
|
| Rate for Payer: Medicare All Medicare |
$197.40
|
| Rate for Payer: Monida Allegiance |
$267.90
|
| Rate for Payer: Monida First Choice Health |
$273.54
|
| Rate for Payer: Monida Montana Health Co-op |
$267.90
|
| Rate for Payer: Monida PacificSource |
$267.90
|
|
|
TR DRESS/DEBRIDE BURN >10%TOTAL LARGE
|
Facility
|
OP
|
$525.00
|
|
|
Service Code
|
CPT 16030
|
| Hospital Charge Code |
1046030
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$367.50 |
| Max. Negotiated Rate |
$525.00 |
| Rate for Payer: Aetna Commercial |
$498.75
|
| Rate for Payer: Aetna Medicare |
$472.50
|
| Rate for Payer: BCBS MT CHIP |
$472.50
|
| Rate for Payer: BCBS MT Closed Plan Network |
$498.75
|
| Rate for Payer: BCBS MT HealthLink |
$472.50
|
| Rate for Payer: BCBS MT Medicare |
$472.50
|
| Rate for Payer: BCBS MT POS |
$498.75
|
| Rate for Payer: BCBS MT Traditional |
$525.00
|
| Rate for Payer: Cash Price |
$472.50
|
| Rate for Payer: Cigna Commercial |
$498.75
|
| Rate for Payer: Cigna Medicare |
$472.50
|
| Rate for Payer: Medicaid All Medicaid |
$483.00
|
| Rate for Payer: Medicare All Medicare |
$367.50
|
| Rate for Payer: Monida Allegiance |
$498.75
|
| Rate for Payer: Monida First Choice Health |
$509.25
|
| Rate for Payer: Monida Montana Health Co-op |
$498.75
|
| Rate for Payer: Monida PacificSource |
$498.75
|
|
|
TR DRESS/DEBRIDE BURN >10%TOTAL LARGE
|
Facility
|
IP
|
$525.00
|
|
|
Service Code
|
CPT 16030
|
| Hospital Charge Code |
1046030
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$367.50 |
| Max. Negotiated Rate |
$525.00 |
| Rate for Payer: Aetna Commercial |
$498.75
|
| Rate for Payer: Aetna Medicare |
$472.50
|
| Rate for Payer: BCBS MT CHIP |
$472.50
|
| Rate for Payer: BCBS MT Closed Plan Network |
$498.75
|
| Rate for Payer: BCBS MT HealthLink |
$472.50
|
| Rate for Payer: BCBS MT Medicare |
$472.50
|
| Rate for Payer: BCBS MT POS |
$498.75
|
| Rate for Payer: BCBS MT Traditional |
$525.00
|
| Rate for Payer: Cash Price |
$472.50
|
| Rate for Payer: Cigna Commercial |
$498.75
|
| Rate for Payer: Cigna Medicare |
$472.50
|
| Rate for Payer: Medicaid All Medicaid |
$483.00
|
| Rate for Payer: Medicare All Medicare |
$367.50
|
| Rate for Payer: Monida Allegiance |
$498.75
|
| Rate for Payer: Monida First Choice Health |
$509.25
|
| Rate for Payer: Monida Montana Health Co-op |
$498.75
|
| Rate for Payer: Monida PacificSource |
$498.75
|
|
|
TREAT FRACTURE RADIUS & ULNA W/MANI
|
Facility
|
OP
|
$773.00
|
|
|
Service Code
|
CPT 25565
|
| Hospital Charge Code |
1025565
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$541.10 |
| Max. Negotiated Rate |
$773.00 |
| Rate for Payer: Aetna Commercial |
$734.35
|
| Rate for Payer: Aetna Medicare |
$695.70
|
| Rate for Payer: BCBS MT CHIP |
$695.70
|
| Rate for Payer: BCBS MT Closed Plan Network |
$734.35
|
| Rate for Payer: BCBS MT HealthLink |
$695.70
|
| Rate for Payer: BCBS MT Medicare |
$695.70
|
| Rate for Payer: BCBS MT POS |
$734.35
|
| Rate for Payer: BCBS MT Traditional |
$773.00
|
| Rate for Payer: Cash Price |
$695.70
|
| Rate for Payer: Cigna Commercial |
$734.35
|
| Rate for Payer: Cigna Medicare |
$695.70
|
| Rate for Payer: Medicaid All Medicaid |
$711.16
|
| Rate for Payer: Medicare All Medicare |
$541.10
|
| Rate for Payer: Monida Allegiance |
$734.35
|
| Rate for Payer: Monida First Choice Health |
$749.81
|
| Rate for Payer: Monida Montana Health Co-op |
$734.35
|
| Rate for Payer: Monida PacificSource |
$734.35
|
|
|
TREAT FRACTURE RADIUS & ULNA W/MANI
|
Facility
|
IP
|
$773.00
|
|
|
Service Code
|
CPT 25565
|
| Hospital Charge Code |
1025565
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$541.10 |
| Max. Negotiated Rate |
$773.00 |
| Rate for Payer: Aetna Commercial |
$734.35
|
| Rate for Payer: Aetna Medicare |
$695.70
|
| Rate for Payer: BCBS MT CHIP |
$695.70
|
| Rate for Payer: BCBS MT Closed Plan Network |
$734.35
|
| Rate for Payer: BCBS MT HealthLink |
$695.70
|
| Rate for Payer: BCBS MT Medicare |
$695.70
|
| Rate for Payer: BCBS MT POS |
$734.35
|
| Rate for Payer: BCBS MT Traditional |
$773.00
|
| Rate for Payer: Cash Price |
$695.70
|
| Rate for Payer: Cigna Commercial |
$734.35
|
| Rate for Payer: Cigna Medicare |
$695.70
|
| Rate for Payer: Medicaid All Medicaid |
$711.16
|
| Rate for Payer: Medicare All Medicare |
$541.10
|
| Rate for Payer: Monida Allegiance |
$734.35
|
| Rate for Payer: Monida First Choice Health |
$749.81
|
| Rate for Payer: Monida Montana Health Co-op |
$734.35
|
| Rate for Payer: Monida PacificSource |
$734.35
|
|
|
TREATMENT RM
|
Facility
|
IP
|
$1,649.00
|
|
|
Service Code
|
CPT 36556
|
| Hospital Charge Code |
1036556
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,154.30 |
| Max. Negotiated Rate |
$1,649.00 |
| Rate for Payer: Aetna Commercial |
$1,566.55
|
| Rate for Payer: Aetna Medicare |
$1,484.10
|
| Rate for Payer: BCBS MT CHIP |
$1,484.10
|
| Rate for Payer: BCBS MT Closed Plan Network |
$1,566.55
|
| Rate for Payer: BCBS MT HealthLink |
$1,484.10
|
| Rate for Payer: BCBS MT Medicare |
$1,484.10
|
| Rate for Payer: BCBS MT POS |
$1,566.55
|
| Rate for Payer: BCBS MT Traditional |
$1,649.00
|
| Rate for Payer: Cash Price |
$1,484.10
|
| Rate for Payer: Cigna Commercial |
$1,566.55
|
| Rate for Payer: Cigna Medicare |
$1,484.10
|
| Rate for Payer: Medicaid All Medicaid |
$1,517.08
|
| Rate for Payer: Medicare All Medicare |
$1,154.30
|
| Rate for Payer: Monida Allegiance |
$1,566.55
|
| Rate for Payer: Monida First Choice Health |
$1,599.53
|
| Rate for Payer: Monida Montana Health Co-op |
$1,566.55
|
| Rate for Payer: Monida PacificSource |
$1,566.55
|
|
|
TREATMENT RM
|
Facility
|
OP
|
$1,649.00
|
|
|
Service Code
|
CPT 36556
|
| Hospital Charge Code |
1036556
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,154.30 |
| Max. Negotiated Rate |
$1,649.00 |
| Rate for Payer: Aetna Commercial |
$1,566.55
|
| Rate for Payer: Aetna Medicare |
$1,484.10
|
| Rate for Payer: BCBS MT CHIP |
$1,484.10
|
| Rate for Payer: BCBS MT Closed Plan Network |
$1,566.55
|
| Rate for Payer: BCBS MT HealthLink |
$1,484.10
|
| Rate for Payer: BCBS MT Medicare |
$1,484.10
|
| Rate for Payer: BCBS MT POS |
$1,566.55
|
| Rate for Payer: BCBS MT Traditional |
$1,649.00
|
| Rate for Payer: Cash Price |
$1,484.10
|
| Rate for Payer: Cigna Commercial |
$1,566.55
|
| Rate for Payer: Cigna Medicare |
$1,484.10
|
| Rate for Payer: Medicaid All Medicaid |
$1,517.08
|
| Rate for Payer: Medicare All Medicare |
$1,154.30
|
| Rate for Payer: Monida Allegiance |
$1,566.55
|
| Rate for Payer: Monida First Choice Health |
$1,599.53
|
| Rate for Payer: Monida Montana Health Co-op |
$1,566.55
|
| Rate for Payer: Monida PacificSource |
$1,566.55
|
|
|
TREATMENT RM CHG TUBE GASTROSTOMY
|
Facility
|
OP
|
$585.00
|
|
|
Service Code
|
CPT 43760
|
| Hospital Charge Code |
1043760
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$409.50 |
| Max. Negotiated Rate |
$585.00 |
| Rate for Payer: Aetna Commercial |
$555.75
|
| Rate for Payer: Aetna Medicare |
$526.50
|
| Rate for Payer: BCBS MT CHIP |
$526.50
|
| Rate for Payer: BCBS MT Closed Plan Network |
$555.75
|
| Rate for Payer: BCBS MT HealthLink |
$526.50
|
| Rate for Payer: BCBS MT Medicare |
$526.50
|
| Rate for Payer: BCBS MT POS |
$555.75
|
| Rate for Payer: BCBS MT Traditional |
$585.00
|
| Rate for Payer: Cash Price |
$526.50
|
| Rate for Payer: Cigna Commercial |
$555.75
|
| Rate for Payer: Cigna Medicare |
$526.50
|
| Rate for Payer: Medicaid All Medicaid |
$538.20
|
| Rate for Payer: Medicare All Medicare |
$409.50
|
| Rate for Payer: Monida Allegiance |
$555.75
|
| Rate for Payer: Monida First Choice Health |
$567.45
|
| Rate for Payer: Monida Montana Health Co-op |
$555.75
|
| Rate for Payer: Monida PacificSource |
$555.75
|
|
|
TREATMENT RM CHG TUBE GASTROSTOMY
|
Facility
|
IP
|
$585.00
|
|
|
Service Code
|
CPT 43760
|
| Hospital Charge Code |
1043760
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$409.50 |
| Max. Negotiated Rate |
$585.00 |
| Rate for Payer: Aetna Commercial |
$555.75
|
| Rate for Payer: Aetna Medicare |
$526.50
|
| Rate for Payer: BCBS MT CHIP |
$526.50
|
| Rate for Payer: BCBS MT Closed Plan Network |
$555.75
|
| Rate for Payer: BCBS MT HealthLink |
$526.50
|
| Rate for Payer: BCBS MT Medicare |
$526.50
|
| Rate for Payer: BCBS MT POS |
$555.75
|
| Rate for Payer: BCBS MT Traditional |
$585.00
|
| Rate for Payer: Cash Price |
$526.50
|
| Rate for Payer: Cigna Commercial |
$555.75
|
| Rate for Payer: Cigna Medicare |
$526.50
|
| Rate for Payer: Medicaid All Medicaid |
$538.20
|
| Rate for Payer: Medicare All Medicare |
$409.50
|
| Rate for Payer: Monida Allegiance |
$555.75
|
| Rate for Payer: Monida First Choice Health |
$567.45
|
| Rate for Payer: Monida Montana Health Co-op |
$555.75
|
| Rate for Payer: Monida PacificSource |
$555.75
|
|
