|
VIT B12 ASSAY
|
Facility
|
IP
|
$119.48
|
|
| Hospital Charge Code |
90197100
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$83.64 |
| Max. Negotiated Rate |
$119.48 |
| Rate for Payer: Aetna Commercial |
$113.51
|
| Rate for Payer: Aetna Medicare |
$107.53
|
| Rate for Payer: BCBS MT CHIP |
$107.53
|
| Rate for Payer: BCBS MT Closed Plan Network |
$113.51
|
| Rate for Payer: BCBS MT HealthLink |
$107.53
|
| Rate for Payer: BCBS MT Medicare |
$107.53
|
| Rate for Payer: BCBS MT POS |
$113.51
|
| Rate for Payer: BCBS MT Traditional |
$119.48
|
| Rate for Payer: Cash Price |
$107.53
|
| Rate for Payer: Cigna Commercial |
$113.51
|
| Rate for Payer: Cigna Medicare |
$107.53
|
| Rate for Payer: Medicaid All Medicaid |
$109.92
|
| Rate for Payer: Medicare All Medicare |
$83.64
|
| Rate for Payer: Monida Allegiance |
$113.51
|
| Rate for Payer: Monida First Choice Health |
$115.90
|
| Rate for Payer: Monida Montana Health Co-op |
$113.51
|
| Rate for Payer: Monida PacificSource |
$113.51
|
|
|
VIT B12 + FOLATE
|
Facility
|
OP
|
$150.00
|
|
|
Service Code
|
CPT 82607
|
| Hospital Charge Code |
4087979
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$105.00 |
| Max. Negotiated Rate |
$150.00 |
| Rate for Payer: Aetna Commercial |
$142.50
|
| Rate for Payer: Aetna Medicare |
$135.00
|
| Rate for Payer: BCBS MT CHIP |
$135.00
|
| Rate for Payer: BCBS MT Closed Plan Network |
$142.50
|
| Rate for Payer: BCBS MT HealthLink |
$135.00
|
| Rate for Payer: BCBS MT Medicare |
$135.00
|
| Rate for Payer: BCBS MT POS |
$142.50
|
| Rate for Payer: BCBS MT Traditional |
$150.00
|
| Rate for Payer: Cash Price |
$135.00
|
| Rate for Payer: Cigna Commercial |
$142.50
|
| Rate for Payer: Cigna Medicare |
$135.00
|
| Rate for Payer: Medicaid All Medicaid |
$138.00
|
| Rate for Payer: Medicare All Medicare |
$105.00
|
| Rate for Payer: Monida Allegiance |
$142.50
|
| Rate for Payer: Monida First Choice Health |
$145.50
|
| Rate for Payer: Monida Montana Health Co-op |
$142.50
|
| Rate for Payer: Monida PacificSource |
$142.50
|
|
|
VIT B12 + FOLATE
|
Facility
|
IP
|
$150.00
|
|
|
Service Code
|
CPT 82607
|
| Hospital Charge Code |
4087979
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$105.00 |
| Max. Negotiated Rate |
$150.00 |
| Rate for Payer: Aetna Commercial |
$142.50
|
| Rate for Payer: Aetna Medicare |
$135.00
|
| Rate for Payer: BCBS MT CHIP |
$135.00
|
| Rate for Payer: BCBS MT Closed Plan Network |
$142.50
|
| Rate for Payer: BCBS MT HealthLink |
$135.00
|
| Rate for Payer: BCBS MT Medicare |
$135.00
|
| Rate for Payer: BCBS MT POS |
$142.50
|
| Rate for Payer: BCBS MT Traditional |
$150.00
|
| Rate for Payer: Cash Price |
$135.00
|
| Rate for Payer: Cigna Commercial |
$142.50
|
| Rate for Payer: Cigna Medicare |
$135.00
|
| Rate for Payer: Medicaid All Medicaid |
$138.00
|
| Rate for Payer: Medicare All Medicare |
$105.00
|
| Rate for Payer: Monida Allegiance |
$142.50
|
| Rate for Payer: Monida First Choice Health |
$145.50
|
| Rate for Payer: Monida Montana Health Co-op |
$142.50
|
| Rate for Payer: Monida PacificSource |
$142.50
|
|
|
VOLDYNE VOLUME EXERCISER
|
Facility
|
OP
|
$19.00
|
|
| Hospital Charge Code |
2840349
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$13.30 |
| Max. Negotiated Rate |
$19.00 |
| Rate for Payer: Aetna Commercial |
$18.05
|
| Rate for Payer: Aetna Medicare |
$17.10
|
| Rate for Payer: BCBS MT CHIP |
$17.10
|
| Rate for Payer: BCBS MT Closed Plan Network |
$18.05
|
| Rate for Payer: BCBS MT HealthLink |
$17.10
|
| Rate for Payer: BCBS MT Medicare |
$17.10
|
| Rate for Payer: BCBS MT POS |
$18.05
|
| Rate for Payer: BCBS MT Traditional |
$19.00
|
| Rate for Payer: Cash Price |
$17.10
|
| Rate for Payer: Cigna Commercial |
$18.05
|
| Rate for Payer: Cigna Medicare |
$17.10
|
| Rate for Payer: Medicaid All Medicaid |
$17.48
|
| Rate for Payer: Medicare All Medicare |
$13.30
|
| Rate for Payer: Monida Allegiance |
$18.05
|
| Rate for Payer: Monida First Choice Health |
$18.43
|
| Rate for Payer: Monida Montana Health Co-op |
$18.05
|
| Rate for Payer: Monida PacificSource |
$18.05
|
|
|
VOLDYNE VOLUME EXERCISER
|
Facility
|
IP
|
$19.00
|
|
| Hospital Charge Code |
2840349
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$13.30 |
| Max. Negotiated Rate |
$19.00 |
| Rate for Payer: Aetna Commercial |
$18.05
|
| Rate for Payer: Aetna Medicare |
$17.10
|
| Rate for Payer: BCBS MT CHIP |
$17.10
|
| Rate for Payer: BCBS MT Closed Plan Network |
$18.05
|
| Rate for Payer: BCBS MT HealthLink |
$17.10
|
| Rate for Payer: BCBS MT Medicare |
$17.10
|
| Rate for Payer: BCBS MT POS |
$18.05
|
| Rate for Payer: BCBS MT Traditional |
$19.00
|
| Rate for Payer: Cash Price |
$17.10
|
| Rate for Payer: Cigna Commercial |
$18.05
|
| Rate for Payer: Cigna Medicare |
$17.10
|
| Rate for Payer: Medicaid All Medicaid |
$17.48
|
| Rate for Payer: Medicare All Medicare |
$13.30
|
| Rate for Payer: Monida Allegiance |
$18.05
|
| Rate for Payer: Monida First Choice Health |
$18.43
|
| Rate for Payer: Monida Montana Health Co-op |
$18.05
|
| Rate for Payer: Monida PacificSource |
$18.05
|
|
|
.VOLUME MEASUREMENT, TIMED COLLECTION
|
Facility
|
IP
|
$30.00
|
|
|
Service Code
|
CPT 81050
|
| Hospital Charge Code |
4081050
|
|
Hospital Revenue Code
|
307
|
| Min. Negotiated Rate |
$21.00 |
| Max. Negotiated Rate |
$30.00 |
| Rate for Payer: Aetna Commercial |
$28.50
|
| Rate for Payer: Aetna Medicare |
$27.00
|
| Rate for Payer: BCBS MT CHIP |
$27.00
|
| Rate for Payer: BCBS MT Closed Plan Network |
$28.50
|
| Rate for Payer: BCBS MT HealthLink |
$27.00
|
| Rate for Payer: BCBS MT Medicare |
$27.00
|
| Rate for Payer: BCBS MT POS |
$28.50
|
| Rate for Payer: BCBS MT Traditional |
$30.00
|
| Rate for Payer: Cash Price |
$27.00
|
| Rate for Payer: Cigna Commercial |
$28.50
|
| Rate for Payer: Cigna Medicare |
$27.00
|
| Rate for Payer: Medicaid All Medicaid |
$27.60
|
| Rate for Payer: Medicare All Medicare |
$21.00
|
| Rate for Payer: Monida Allegiance |
$28.50
|
| Rate for Payer: Monida First Choice Health |
$29.10
|
| Rate for Payer: Monida Montana Health Co-op |
$28.50
|
| Rate for Payer: Monida PacificSource |
$28.50
|
|
|
.VOLUME MEASUREMENT, TIMED COLLECTION
|
Facility
|
OP
|
$30.00
|
|
|
Service Code
|
CPT 81050
|
| Hospital Charge Code |
4081050
|
|
Hospital Revenue Code
|
307
|
| Min. Negotiated Rate |
$21.00 |
| Max. Negotiated Rate |
$30.00 |
| Rate for Payer: Aetna Commercial |
$28.50
|
| Rate for Payer: Aetna Medicare |
$27.00
|
| Rate for Payer: BCBS MT CHIP |
$27.00
|
| Rate for Payer: BCBS MT Closed Plan Network |
$28.50
|
| Rate for Payer: BCBS MT HealthLink |
$27.00
|
| Rate for Payer: BCBS MT Medicare |
$27.00
|
| Rate for Payer: BCBS MT POS |
$28.50
|
| Rate for Payer: BCBS MT Traditional |
$30.00
|
| Rate for Payer: Cash Price |
$27.00
|
| Rate for Payer: Cigna Commercial |
$28.50
|
| Rate for Payer: Cigna Medicare |
$27.00
|
| Rate for Payer: Medicaid All Medicaid |
$27.60
|
| Rate for Payer: Medicare All Medicare |
$21.00
|
| Rate for Payer: Monida Allegiance |
$28.50
|
| Rate for Payer: Monida First Choice Health |
$29.10
|
| Rate for Payer: Monida Montana Health Co-op |
$28.50
|
| Rate for Payer: Monida PacificSource |
$28.50
|
|
|
VON WILLEBRAND FACT ACTIVITY (ARUP30250)
|
Facility
|
OP
|
$100.00
|
|
|
Service Code
|
CPT 85245
|
| Hospital Charge Code |
4085245
|
|
Hospital Revenue Code
|
300
|
| 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
|
|
|
VON WILLEBRAND FACT ACTIVITY (ARUP30250)
|
Facility
|
IP
|
$100.00
|
|
|
Service Code
|
CPT 85245
|
| Hospital Charge Code |
4085245
|
|
Hospital Revenue Code
|
300
|
| 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
|
|
|
VON WILLEBRAND FACTOR ANTIGEN (086280)
|
Facility
|
OP
|
$100.00
|
|
|
Service Code
|
CPT 85246
|
| Hospital Charge Code |
4085246
|
|
Hospital Revenue Code
|
300
|
| 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
|
|
|
VON WILLEBRAND FACTOR ANTIGEN (086280)
|
Facility
|
IP
|
$100.00
|
|
|
Service Code
|
CPT 85246
|
| Hospital Charge Code |
4085246
|
|
Hospital Revenue Code
|
300
|
| 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
|
|
|
VORICONAZOLE TAB [200 MG] NF
|
Facility
|
OP
|
$267.00
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
3000483
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$186.90 |
| Max. Negotiated Rate |
$267.00 |
| Rate for Payer: Aetna Commercial |
$253.65
|
| Rate for Payer: Aetna Medicare |
$240.30
|
| Rate for Payer: BCBS MT CHIP |
$240.30
|
| Rate for Payer: BCBS MT Closed Plan Network |
$253.65
|
| Rate for Payer: BCBS MT HealthLink |
$240.30
|
| Rate for Payer: BCBS MT Medicare |
$240.30
|
| Rate for Payer: BCBS MT POS |
$253.65
|
| Rate for Payer: BCBS MT Traditional |
$267.00
|
| Rate for Payer: Cash Price |
$240.30
|
| Rate for Payer: Cigna Commercial |
$253.65
|
| Rate for Payer: Cigna Medicare |
$240.30
|
| Rate for Payer: Medicaid All Medicaid |
$245.64
|
| Rate for Payer: Medicare All Medicare |
$186.90
|
| Rate for Payer: Monida Allegiance |
$253.65
|
| Rate for Payer: Monida First Choice Health |
$258.99
|
| Rate for Payer: Monida Montana Health Co-op |
$253.65
|
| Rate for Payer: Monida PacificSource |
$253.65
|
|
|
VORICONAZOLE TAB [200 MG] NF
|
Facility
|
IP
|
$267.00
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
3000483
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$186.90 |
| Max. Negotiated Rate |
$267.00 |
| Rate for Payer: Aetna Commercial |
$253.65
|
| Rate for Payer: Aetna Medicare |
$240.30
|
| Rate for Payer: BCBS MT CHIP |
$240.30
|
| Rate for Payer: BCBS MT Closed Plan Network |
$253.65
|
| Rate for Payer: BCBS MT HealthLink |
$240.30
|
| Rate for Payer: BCBS MT Medicare |
$240.30
|
| Rate for Payer: BCBS MT POS |
$253.65
|
| Rate for Payer: BCBS MT Traditional |
$267.00
|
| Rate for Payer: Cash Price |
$240.30
|
| Rate for Payer: Cigna Commercial |
$253.65
|
| Rate for Payer: Cigna Medicare |
$240.30
|
| Rate for Payer: Medicaid All Medicaid |
$245.64
|
| Rate for Payer: Medicare All Medicare |
$186.90
|
| Rate for Payer: Monida Allegiance |
$253.65
|
| Rate for Payer: Monida First Choice Health |
$258.99
|
| Rate for Payer: Monida Montana Health Co-op |
$253.65
|
| Rate for Payer: Monida PacificSource |
$253.65
|
|
|
WARFARIN TAB [1 MG]
|
Facility
|
OP
|
$8.00
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
3000484
|
|
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
|
|
|
WARFARIN TAB [1 MG]
|
Facility
|
IP
|
$8.00
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
3000484
|
|
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
|
|
|
WARFARIN TAB [2 MG] NF
|
Facility
|
IP
|
$8.00
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
3000485
|
|
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
|
|
|
WARFARIN TAB [2 MG] NF
|
Facility
|
OP
|
$8.00
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
3000485
|
|
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
|
|
|
WARFARIN TAB [5 MG]
|
Facility
|
IP
|
$8.00
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
3000486
|
|
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
|
|
|
WARFARIN TAB [5 MG]
|
Facility
|
OP
|
$8.00
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
3000486
|
|
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
|
|
|
WELCOME TO MEDICARE EXAM
|
Facility
|
OP
|
$382.00
|
|
|
Service Code
|
HCPCS G0402
|
| Hospital Charge Code |
8000402
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$267.40 |
| Max. Negotiated Rate |
$382.00 |
| Rate for Payer: Aetna Commercial |
$362.90
|
| Rate for Payer: Aetna Medicare |
$343.80
|
| Rate for Payer: BCBS MT CHIP |
$343.80
|
| Rate for Payer: BCBS MT Closed Plan Network |
$362.90
|
| Rate for Payer: BCBS MT HealthLink |
$343.80
|
| Rate for Payer: BCBS MT Medicare |
$343.80
|
| Rate for Payer: BCBS MT POS |
$362.90
|
| Rate for Payer: BCBS MT Traditional |
$382.00
|
| Rate for Payer: Cash Price |
$343.80
|
| Rate for Payer: Cigna Commercial |
$362.90
|
| Rate for Payer: Cigna Medicare |
$343.80
|
| Rate for Payer: Medicaid All Medicaid |
$351.44
|
| Rate for Payer: Medicare All Medicare |
$267.40
|
| Rate for Payer: Monida Allegiance |
$362.90
|
| Rate for Payer: Monida First Choice Health |
$370.54
|
| Rate for Payer: Monida Montana Health Co-op |
$362.90
|
| Rate for Payer: Monida PacificSource |
$362.90
|
|
|
WELCOME TO MEDICARE EXAM
|
Facility
|
IP
|
$382.00
|
|
|
Service Code
|
HCPCS G0402
|
| Hospital Charge Code |
8000402
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$267.40 |
| Max. Negotiated Rate |
$382.00 |
| Rate for Payer: Aetna Commercial |
$362.90
|
| Rate for Payer: Aetna Medicare |
$343.80
|
| Rate for Payer: BCBS MT CHIP |
$343.80
|
| Rate for Payer: BCBS MT Closed Plan Network |
$362.90
|
| Rate for Payer: BCBS MT HealthLink |
$343.80
|
| Rate for Payer: BCBS MT Medicare |
$343.80
|
| Rate for Payer: BCBS MT POS |
$362.90
|
| Rate for Payer: BCBS MT Traditional |
$382.00
|
| Rate for Payer: Cash Price |
$343.80
|
| Rate for Payer: Cigna Commercial |
$362.90
|
| Rate for Payer: Cigna Medicare |
$343.80
|
| Rate for Payer: Medicaid All Medicaid |
$351.44
|
| Rate for Payer: Medicare All Medicare |
$267.40
|
| Rate for Payer: Monida Allegiance |
$362.90
|
| Rate for Payer: Monida First Choice Health |
$370.54
|
| Rate for Payer: Monida Montana Health Co-op |
$362.90
|
| Rate for Payer: Monida PacificSource |
$362.90
|
|
|
WET MOUNT, VAGINAL
|
Facility
|
IP
|
$78.00
|
|
|
Service Code
|
CPT 87210
|
| Hospital Charge Code |
4087210
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$54.60 |
| Max. Negotiated Rate |
$78.00 |
| Rate for Payer: Aetna Commercial |
$74.10
|
| Rate for Payer: Aetna Medicare |
$70.20
|
| Rate for Payer: BCBS MT CHIP |
$70.20
|
| Rate for Payer: BCBS MT Closed Plan Network |
$74.10
|
| Rate for Payer: BCBS MT HealthLink |
$70.20
|
| Rate for Payer: BCBS MT Medicare |
$70.20
|
| Rate for Payer: BCBS MT POS |
$74.10
|
| Rate for Payer: BCBS MT Traditional |
$78.00
|
| Rate for Payer: Cash Price |
$70.20
|
| Rate for Payer: Cigna Commercial |
$74.10
|
| Rate for Payer: Cigna Medicare |
$70.20
|
| Rate for Payer: Medicaid All Medicaid |
$71.76
|
| Rate for Payer: Medicare All Medicare |
$54.60
|
| Rate for Payer: Monida Allegiance |
$74.10
|
| Rate for Payer: Monida First Choice Health |
$75.66
|
| Rate for Payer: Monida Montana Health Co-op |
$74.10
|
| Rate for Payer: Monida PacificSource |
$74.10
|
|
|
WET MOUNT, VAGINAL
|
Facility
|
OP
|
$78.00
|
|
|
Service Code
|
CPT 87210
|
| Hospital Charge Code |
4087210
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$54.60 |
| Max. Negotiated Rate |
$78.00 |
| Rate for Payer: Aetna Commercial |
$74.10
|
| Rate for Payer: Aetna Medicare |
$70.20
|
| Rate for Payer: BCBS MT CHIP |
$70.20
|
| Rate for Payer: BCBS MT Closed Plan Network |
$74.10
|
| Rate for Payer: BCBS MT HealthLink |
$70.20
|
| Rate for Payer: BCBS MT Medicare |
$70.20
|
| Rate for Payer: BCBS MT POS |
$74.10
|
| Rate for Payer: BCBS MT Traditional |
$78.00
|
| Rate for Payer: Cash Price |
$70.20
|
| Rate for Payer: Cigna Commercial |
$74.10
|
| Rate for Payer: Cigna Medicare |
$70.20
|
| Rate for Payer: Medicaid All Medicaid |
$71.76
|
| Rate for Payer: Medicare All Medicare |
$54.60
|
| Rate for Payer: Monida Allegiance |
$74.10
|
| Rate for Payer: Monida First Choice Health |
$75.66
|
| Rate for Payer: Monida Montana Health Co-op |
$74.10
|
| Rate for Payer: Monida PacificSource |
$74.10
|
|
|
WHITE BLOOD CELL COUNT, BLOOD
|
Facility
|
OP
|
$42.00
|
|
|
Service Code
|
CPT 85048
|
| Hospital Charge Code |
4085048
|
|
Hospital Revenue Code
|
305
|
| 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
|
|
|
WHITE BLOOD CELL COUNT, BLOOD
|
Facility
|
IP
|
$42.00
|
|
|
Service Code
|
CPT 85048
|
| Hospital Charge Code |
4085048
|
|
Hospital Revenue Code
|
305
|
| 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
|
|
