|
COLONOSCOPY W/REMVL-HOT BPSY FCPS 45384
|
Facility
|
OP
|
$2,883.00
|
|
|
Service Code
|
HCPCS 45384
|
| Hospital Charge Code |
5845384
|
|
Hospital Revenue Code
|
750
|
| Min. Negotiated Rate |
$2,018.10 |
| Max. Negotiated Rate |
$2,883.00 |
| Rate for Payer: Aetna Commercial |
$2,738.85
|
| Rate for Payer: Aetna Medicare |
$2,594.70
|
| Rate for Payer: BCBS MT CHIP |
$2,594.70
|
| Rate for Payer: BCBS MT Closed Plan Network |
$2,738.85
|
| Rate for Payer: BCBS MT HealthLink |
$2,594.70
|
| Rate for Payer: BCBS MT Medicare |
$2,594.70
|
| Rate for Payer: BCBS MT POS |
$2,738.85
|
| Rate for Payer: BCBS MT Traditional |
$2,883.00
|
| Rate for Payer: Cash Price |
$2,594.70
|
| Rate for Payer: Cigna Commercial |
$2,738.85
|
| Rate for Payer: Cigna Medicare |
$2,594.70
|
| Rate for Payer: Medicaid All Medicaid |
$2,652.36
|
| Rate for Payer: Medicare All Medicare |
$2,018.10
|
| Rate for Payer: Monida Allegiance |
$2,738.85
|
| Rate for Payer: Monida First Choice Health |
$2,796.51
|
| Rate for Payer: Monida Montana Health Co-op |
$2,738.85
|
| Rate for Payer: Monida PacificSource |
$2,738.85
|
|
|
COLONOSCOPY W/REMVL-HOT BPSY FCPS 45384
|
Facility
|
IP
|
$2,883.00
|
|
|
Service Code
|
HCPCS 45384
|
| Hospital Charge Code |
5845384
|
|
Hospital Revenue Code
|
750
|
| Min. Negotiated Rate |
$2,018.10 |
| Max. Negotiated Rate |
$2,883.00 |
| Rate for Payer: Aetna Commercial |
$2,738.85
|
| Rate for Payer: Aetna Medicare |
$2,594.70
|
| Rate for Payer: BCBS MT CHIP |
$2,594.70
|
| Rate for Payer: BCBS MT Closed Plan Network |
$2,738.85
|
| Rate for Payer: BCBS MT HealthLink |
$2,594.70
|
| Rate for Payer: BCBS MT Medicare |
$2,594.70
|
| Rate for Payer: BCBS MT POS |
$2,738.85
|
| Rate for Payer: BCBS MT Traditional |
$2,883.00
|
| Rate for Payer: Cash Price |
$2,594.70
|
| Rate for Payer: Cigna Commercial |
$2,738.85
|
| Rate for Payer: Cigna Medicare |
$2,594.70
|
| Rate for Payer: Medicaid All Medicaid |
$2,652.36
|
| Rate for Payer: Medicare All Medicare |
$2,018.10
|
| Rate for Payer: Monida Allegiance |
$2,738.85
|
| Rate for Payer: Monida First Choice Health |
$2,796.51
|
| Rate for Payer: Monida Montana Health Co-op |
$2,738.85
|
| Rate for Payer: Monida PacificSource |
$2,738.85
|
|
|
COLONOSCOPY W/RMVL-SNARE TECHNQ 45385
|
Facility
|
OP
|
$2,882.00
|
|
|
Service Code
|
HCPCS 45385
|
| Hospital Charge Code |
5845385
|
|
Hospital Revenue Code
|
750
|
| Min. Negotiated Rate |
$2,017.40 |
| Max. Negotiated Rate |
$2,882.00 |
| Rate for Payer: Aetna Commercial |
$2,737.90
|
| Rate for Payer: Aetna Medicare |
$2,593.80
|
| Rate for Payer: BCBS MT CHIP |
$2,593.80
|
| Rate for Payer: BCBS MT Closed Plan Network |
$2,737.90
|
| Rate for Payer: BCBS MT HealthLink |
$2,593.80
|
| Rate for Payer: BCBS MT Medicare |
$2,593.80
|
| Rate for Payer: BCBS MT POS |
$2,737.90
|
| Rate for Payer: BCBS MT Traditional |
$2,882.00
|
| Rate for Payer: Cash Price |
$2,593.80
|
| Rate for Payer: Cigna Commercial |
$2,737.90
|
| Rate for Payer: Cigna Medicare |
$2,593.80
|
| Rate for Payer: Medicaid All Medicaid |
$2,651.44
|
| Rate for Payer: Medicare All Medicare |
$2,017.40
|
| Rate for Payer: Monida Allegiance |
$2,737.90
|
| Rate for Payer: Monida First Choice Health |
$2,795.54
|
| Rate for Payer: Monida Montana Health Co-op |
$2,737.90
|
| Rate for Payer: Monida PacificSource |
$2,737.90
|
|
|
COLONOSCOPY W/RMVL-SNARE TECHNQ 45385
|
Facility
|
IP
|
$2,882.00
|
|
|
Service Code
|
HCPCS 45385
|
| Hospital Charge Code |
5845385
|
|
Hospital Revenue Code
|
750
|
| Min. Negotiated Rate |
$2,017.40 |
| Max. Negotiated Rate |
$2,882.00 |
| Rate for Payer: Aetna Commercial |
$2,737.90
|
| Rate for Payer: Aetna Medicare |
$2,593.80
|
| Rate for Payer: BCBS MT CHIP |
$2,593.80
|
| Rate for Payer: BCBS MT Closed Plan Network |
$2,737.90
|
| Rate for Payer: BCBS MT HealthLink |
$2,593.80
|
| Rate for Payer: BCBS MT Medicare |
$2,593.80
|
| Rate for Payer: BCBS MT POS |
$2,737.90
|
| Rate for Payer: BCBS MT Traditional |
$2,882.00
|
| Rate for Payer: Cash Price |
$2,593.80
|
| Rate for Payer: Cigna Commercial |
$2,737.90
|
| Rate for Payer: Cigna Medicare |
$2,593.80
|
| Rate for Payer: Medicaid All Medicaid |
$2,651.44
|
| Rate for Payer: Medicare All Medicare |
$2,017.40
|
| Rate for Payer: Monida Allegiance |
$2,737.90
|
| Rate for Payer: Monida First Choice Health |
$2,795.54
|
| Rate for Payer: Monida Montana Health Co-op |
$2,737.90
|
| Rate for Payer: Monida PacificSource |
$2,737.90
|
|
|
COMBIGAN OPHTH SOLN 0.2%-0.5%-NF
|
Facility
|
OP
|
$563.40
|
|
|
Service Code
|
NDC 00023921105
|
| Hospital Charge Code |
3007265
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$394.38 |
| Max. Negotiated Rate |
$563.40 |
| Rate for Payer: Aetna Commercial |
$535.23
|
| Rate for Payer: Aetna Medicare |
$507.06
|
| Rate for Payer: BCBS MT CHIP |
$507.06
|
| Rate for Payer: BCBS MT Closed Plan Network |
$535.23
|
| Rate for Payer: BCBS MT HealthLink |
$507.06
|
| Rate for Payer: BCBS MT Medicare |
$507.06
|
| Rate for Payer: BCBS MT POS |
$535.23
|
| Rate for Payer: BCBS MT Traditional |
$563.40
|
| Rate for Payer: Cash Price |
$507.06
|
| Rate for Payer: Cigna Commercial |
$535.23
|
| Rate for Payer: Cigna Medicare |
$507.06
|
| Rate for Payer: Medicaid All Medicaid |
$518.33
|
| Rate for Payer: Medicare All Medicare |
$394.38
|
| Rate for Payer: Monida Allegiance |
$535.23
|
| Rate for Payer: Monida First Choice Health |
$546.50
|
| Rate for Payer: Monida Montana Health Co-op |
$535.23
|
| Rate for Payer: Monida PacificSource |
$535.23
|
|
|
COMBIGAN OPHTH SOLN 0.2%-0.5%-NF
|
Facility
|
IP
|
$563.40
|
|
|
Service Code
|
NDC 00023921105
|
| Hospital Charge Code |
3007265
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$394.38 |
| Max. Negotiated Rate |
$563.40 |
| Rate for Payer: Aetna Commercial |
$535.23
|
| Rate for Payer: Aetna Medicare |
$507.06
|
| Rate for Payer: BCBS MT CHIP |
$507.06
|
| Rate for Payer: BCBS MT Closed Plan Network |
$535.23
|
| Rate for Payer: BCBS MT HealthLink |
$507.06
|
| Rate for Payer: BCBS MT Medicare |
$507.06
|
| Rate for Payer: BCBS MT POS |
$535.23
|
| Rate for Payer: BCBS MT Traditional |
$563.40
|
| Rate for Payer: Cash Price |
$507.06
|
| Rate for Payer: Cigna Commercial |
$535.23
|
| Rate for Payer: Cigna Medicare |
$507.06
|
| Rate for Payer: Medicaid All Medicaid |
$518.33
|
| Rate for Payer: Medicare All Medicare |
$394.38
|
| Rate for Payer: Monida Allegiance |
$535.23
|
| Rate for Payer: Monida First Choice Health |
$546.50
|
| Rate for Payer: Monida Montana Health Co-op |
$535.23
|
| Rate for Payer: Monida PacificSource |
$535.23
|
|
|
COMFORT FORM WRIST LT XLG
|
Facility
|
OP
|
$32.00
|
|
| Hospital Charge Code |
2893656
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$22.40 |
| Max. Negotiated Rate |
$32.00 |
| Rate for Payer: Aetna Commercial |
$30.40
|
| Rate for Payer: Aetna Medicare |
$28.80
|
| Rate for Payer: BCBS MT CHIP |
$28.80
|
| Rate for Payer: BCBS MT Closed Plan Network |
$30.40
|
| Rate for Payer: BCBS MT HealthLink |
$28.80
|
| Rate for Payer: BCBS MT Medicare |
$28.80
|
| Rate for Payer: BCBS MT POS |
$30.40
|
| Rate for Payer: BCBS MT Traditional |
$32.00
|
| Rate for Payer: Cash Price |
$28.80
|
| Rate for Payer: Cigna Commercial |
$30.40
|
| Rate for Payer: Cigna Medicare |
$28.80
|
| Rate for Payer: Medicaid All Medicaid |
$29.44
|
| Rate for Payer: Medicare All Medicare |
$22.40
|
| Rate for Payer: Monida Allegiance |
$30.40
|
| Rate for Payer: Monida First Choice Health |
$31.04
|
| Rate for Payer: Monida Montana Health Co-op |
$30.40
|
| Rate for Payer: Monida PacificSource |
$30.40
|
|
|
COMFORT FORM WRIST LT XLG
|
Facility
|
IP
|
$32.00
|
|
| Hospital Charge Code |
2893656
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$22.40 |
| Max. Negotiated Rate |
$32.00 |
| Rate for Payer: Aetna Commercial |
$30.40
|
| Rate for Payer: Aetna Medicare |
$28.80
|
| Rate for Payer: BCBS MT CHIP |
$28.80
|
| Rate for Payer: BCBS MT Closed Plan Network |
$30.40
|
| Rate for Payer: BCBS MT HealthLink |
$28.80
|
| Rate for Payer: BCBS MT Medicare |
$28.80
|
| Rate for Payer: BCBS MT POS |
$30.40
|
| Rate for Payer: BCBS MT Traditional |
$32.00
|
| Rate for Payer: Cash Price |
$28.80
|
| Rate for Payer: Cigna Commercial |
$30.40
|
| Rate for Payer: Cigna Medicare |
$28.80
|
| Rate for Payer: Medicaid All Medicaid |
$29.44
|
| Rate for Payer: Medicare All Medicare |
$22.40
|
| Rate for Payer: Monida Allegiance |
$30.40
|
| Rate for Payer: Monida First Choice Health |
$31.04
|
| Rate for Payer: Monida Montana Health Co-op |
$30.40
|
| Rate for Payer: Monida PacificSource |
$30.40
|
|
|
COMFORT FORM WRIST RT L
|
Facility
|
OP
|
$32.00
|
|
| Hospital Charge Code |
2893651
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$22.40 |
| Max. Negotiated Rate |
$32.00 |
| Rate for Payer: Aetna Commercial |
$30.40
|
| Rate for Payer: Aetna Medicare |
$28.80
|
| Rate for Payer: BCBS MT CHIP |
$28.80
|
| Rate for Payer: BCBS MT Closed Plan Network |
$30.40
|
| Rate for Payer: BCBS MT HealthLink |
$28.80
|
| Rate for Payer: BCBS MT Medicare |
$28.80
|
| Rate for Payer: BCBS MT POS |
$30.40
|
| Rate for Payer: BCBS MT Traditional |
$32.00
|
| Rate for Payer: Cash Price |
$28.80
|
| Rate for Payer: Cigna Commercial |
$30.40
|
| Rate for Payer: Cigna Medicare |
$28.80
|
| Rate for Payer: Medicaid All Medicaid |
$29.44
|
| Rate for Payer: Medicare All Medicare |
$22.40
|
| Rate for Payer: Monida Allegiance |
$30.40
|
| Rate for Payer: Monida First Choice Health |
$31.04
|
| Rate for Payer: Monida Montana Health Co-op |
$30.40
|
| Rate for Payer: Monida PacificSource |
$30.40
|
|
|
COMFORT FORM WRIST RT L
|
Facility
|
IP
|
$32.00
|
|
| Hospital Charge Code |
2893651
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$22.40 |
| Max. Negotiated Rate |
$32.00 |
| Rate for Payer: Aetna Commercial |
$30.40
|
| Rate for Payer: Aetna Medicare |
$28.80
|
| Rate for Payer: BCBS MT CHIP |
$28.80
|
| Rate for Payer: BCBS MT Closed Plan Network |
$30.40
|
| Rate for Payer: BCBS MT HealthLink |
$28.80
|
| Rate for Payer: BCBS MT Medicare |
$28.80
|
| Rate for Payer: BCBS MT POS |
$30.40
|
| Rate for Payer: BCBS MT Traditional |
$32.00
|
| Rate for Payer: Cash Price |
$28.80
|
| Rate for Payer: Cigna Commercial |
$30.40
|
| Rate for Payer: Cigna Medicare |
$28.80
|
| Rate for Payer: Medicaid All Medicaid |
$29.44
|
| Rate for Payer: Medicare All Medicare |
$22.40
|
| Rate for Payer: Monida Allegiance |
$30.40
|
| Rate for Payer: Monida First Choice Health |
$31.04
|
| Rate for Payer: Monida Montana Health Co-op |
$30.40
|
| Rate for Payer: Monida PacificSource |
$30.40
|
|
|
COMFORT FORM WRIST RT M
|
Facility
|
OP
|
$32.00
|
|
| Hospital Charge Code |
2893650
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$22.40 |
| Max. Negotiated Rate |
$32.00 |
| Rate for Payer: Aetna Commercial |
$30.40
|
| Rate for Payer: Aetna Medicare |
$28.80
|
| Rate for Payer: BCBS MT CHIP |
$28.80
|
| Rate for Payer: BCBS MT Closed Plan Network |
$30.40
|
| Rate for Payer: BCBS MT HealthLink |
$28.80
|
| Rate for Payer: BCBS MT Medicare |
$28.80
|
| Rate for Payer: BCBS MT POS |
$30.40
|
| Rate for Payer: BCBS MT Traditional |
$32.00
|
| Rate for Payer: Cash Price |
$28.80
|
| Rate for Payer: Cigna Commercial |
$30.40
|
| Rate for Payer: Cigna Medicare |
$28.80
|
| Rate for Payer: Medicaid All Medicaid |
$29.44
|
| Rate for Payer: Medicare All Medicare |
$22.40
|
| Rate for Payer: Monida Allegiance |
$30.40
|
| Rate for Payer: Monida First Choice Health |
$31.04
|
| Rate for Payer: Monida Montana Health Co-op |
$30.40
|
| Rate for Payer: Monida PacificSource |
$30.40
|
|
|
COMFORT FORM WRIST RT M
|
Facility
|
IP
|
$32.00
|
|
| Hospital Charge Code |
2893650
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$22.40 |
| Max. Negotiated Rate |
$32.00 |
| Rate for Payer: Aetna Commercial |
$30.40
|
| Rate for Payer: Aetna Medicare |
$28.80
|
| Rate for Payer: BCBS MT CHIP |
$28.80
|
| Rate for Payer: BCBS MT Closed Plan Network |
$30.40
|
| Rate for Payer: BCBS MT HealthLink |
$28.80
|
| Rate for Payer: BCBS MT Medicare |
$28.80
|
| Rate for Payer: BCBS MT POS |
$30.40
|
| Rate for Payer: BCBS MT Traditional |
$32.00
|
| Rate for Payer: Cash Price |
$28.80
|
| Rate for Payer: Cigna Commercial |
$30.40
|
| Rate for Payer: Cigna Medicare |
$28.80
|
| Rate for Payer: Medicaid All Medicaid |
$29.44
|
| Rate for Payer: Medicare All Medicare |
$22.40
|
| Rate for Payer: Monida Allegiance |
$30.40
|
| Rate for Payer: Monida First Choice Health |
$31.04
|
| Rate for Payer: Monida Montana Health Co-op |
$30.40
|
| Rate for Payer: Monida PacificSource |
$30.40
|
|
|
COMFORT FORM WRIST RT S
|
Facility
|
OP
|
$37.00
|
|
|
Service Code
|
HCPCS L3908
|
| Hospital Charge Code |
2861597
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$25.90 |
| Max. Negotiated Rate |
$37.00 |
| Rate for Payer: Aetna Commercial |
$35.15
|
| Rate for Payer: Aetna Medicare |
$33.30
|
| Rate for Payer: BCBS MT CHIP |
$33.30
|
| Rate for Payer: BCBS MT Closed Plan Network |
$35.15
|
| Rate for Payer: BCBS MT HealthLink |
$33.30
|
| Rate for Payer: BCBS MT Medicare |
$33.30
|
| Rate for Payer: BCBS MT POS |
$35.15
|
| Rate for Payer: BCBS MT Traditional |
$37.00
|
| Rate for Payer: Cash Price |
$33.30
|
| Rate for Payer: Cigna Commercial |
$35.15
|
| Rate for Payer: Cigna Medicare |
$33.30
|
| Rate for Payer: Medicaid All Medicaid |
$34.04
|
| Rate for Payer: Medicare All Medicare |
$25.90
|
| Rate for Payer: Monida Allegiance |
$35.15
|
| Rate for Payer: Monida First Choice Health |
$35.89
|
| Rate for Payer: Monida Montana Health Co-op |
$35.15
|
| Rate for Payer: Monida PacificSource |
$35.15
|
|
|
COMFORT FORM WRIST RT S
|
Facility
|
IP
|
$37.00
|
|
|
Service Code
|
HCPCS L3908
|
| Hospital Charge Code |
2861597
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$25.90 |
| Max. Negotiated Rate |
$37.00 |
| Rate for Payer: Aetna Commercial |
$35.15
|
| Rate for Payer: Aetna Medicare |
$33.30
|
| Rate for Payer: BCBS MT CHIP |
$33.30
|
| Rate for Payer: BCBS MT Closed Plan Network |
$35.15
|
| Rate for Payer: BCBS MT HealthLink |
$33.30
|
| Rate for Payer: BCBS MT Medicare |
$33.30
|
| Rate for Payer: BCBS MT POS |
$35.15
|
| Rate for Payer: BCBS MT Traditional |
$37.00
|
| Rate for Payer: Cash Price |
$33.30
|
| Rate for Payer: Cigna Commercial |
$35.15
|
| Rate for Payer: Cigna Medicare |
$33.30
|
| Rate for Payer: Medicaid All Medicaid |
$34.04
|
| Rate for Payer: Medicare All Medicare |
$25.90
|
| Rate for Payer: Monida Allegiance |
$35.15
|
| Rate for Payer: Monida First Choice Health |
$35.89
|
| Rate for Payer: Monida Montana Health Co-op |
$35.15
|
| Rate for Payer: Monida PacificSource |
$35.15
|
|
|
COMFORT FORM WRIST RT XLG
|
Facility
|
OP
|
$32.00
|
|
| Hospital Charge Code |
2893652
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$22.40 |
| Max. Negotiated Rate |
$32.00 |
| Rate for Payer: Aetna Commercial |
$30.40
|
| Rate for Payer: Aetna Medicare |
$28.80
|
| Rate for Payer: BCBS MT CHIP |
$28.80
|
| Rate for Payer: BCBS MT Closed Plan Network |
$30.40
|
| Rate for Payer: BCBS MT HealthLink |
$28.80
|
| Rate for Payer: BCBS MT Medicare |
$28.80
|
| Rate for Payer: BCBS MT POS |
$30.40
|
| Rate for Payer: BCBS MT Traditional |
$32.00
|
| Rate for Payer: Cash Price |
$28.80
|
| Rate for Payer: Cigna Commercial |
$30.40
|
| Rate for Payer: Cigna Medicare |
$28.80
|
| Rate for Payer: Medicaid All Medicaid |
$29.44
|
| Rate for Payer: Medicare All Medicare |
$22.40
|
| Rate for Payer: Monida Allegiance |
$30.40
|
| Rate for Payer: Monida First Choice Health |
$31.04
|
| Rate for Payer: Monida Montana Health Co-op |
$30.40
|
| Rate for Payer: Monida PacificSource |
$30.40
|
|
|
COMFORT FORM WRIST RT XLG
|
Facility
|
IP
|
$32.00
|
|
| Hospital Charge Code |
2893652
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$22.40 |
| Max. Negotiated Rate |
$32.00 |
| Rate for Payer: Aetna Commercial |
$30.40
|
| Rate for Payer: Aetna Medicare |
$28.80
|
| Rate for Payer: BCBS MT CHIP |
$28.80
|
| Rate for Payer: BCBS MT Closed Plan Network |
$30.40
|
| Rate for Payer: BCBS MT HealthLink |
$28.80
|
| Rate for Payer: BCBS MT Medicare |
$28.80
|
| Rate for Payer: BCBS MT POS |
$30.40
|
| Rate for Payer: BCBS MT Traditional |
$32.00
|
| Rate for Payer: Cash Price |
$28.80
|
| Rate for Payer: Cigna Commercial |
$30.40
|
| Rate for Payer: Cigna Medicare |
$28.80
|
| Rate for Payer: Medicaid All Medicaid |
$29.44
|
| Rate for Payer: Medicare All Medicare |
$22.40
|
| Rate for Payer: Monida Allegiance |
$30.40
|
| Rate for Payer: Monida First Choice Health |
$31.04
|
| Rate for Payer: Monida Montana Health Co-op |
$30.40
|
| Rate for Payer: Monida PacificSource |
$30.40
|
|
|
COMPLEMENT C1Q (016824)
|
Facility
|
IP
|
$68.00
|
|
|
Service Code
|
HCPCS 86160
|
| Hospital Charge Code |
4086160
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$47.60 |
| Max. Negotiated Rate |
$68.00 |
| Rate for Payer: Aetna Commercial |
$64.60
|
| Rate for Payer: Aetna Medicare |
$61.20
|
| Rate for Payer: BCBS MT CHIP |
$61.20
|
| Rate for Payer: BCBS MT Closed Plan Network |
$64.60
|
| Rate for Payer: BCBS MT HealthLink |
$61.20
|
| Rate for Payer: BCBS MT Medicare |
$61.20
|
| Rate for Payer: BCBS MT POS |
$64.60
|
| Rate for Payer: BCBS MT Traditional |
$68.00
|
| Rate for Payer: Cash Price |
$61.20
|
| Rate for Payer: Cigna Commercial |
$64.60
|
| Rate for Payer: Cigna Medicare |
$61.20
|
| Rate for Payer: Medicaid All Medicaid |
$62.56
|
| Rate for Payer: Medicare All Medicare |
$47.60
|
| Rate for Payer: Monida Allegiance |
$64.60
|
| Rate for Payer: Monida First Choice Health |
$65.96
|
| Rate for Payer: Monida Montana Health Co-op |
$64.60
|
| Rate for Payer: Monida PacificSource |
$64.60
|
|
|
COMPLEMENT C1Q (016824)
|
Facility
|
OP
|
$68.00
|
|
|
Service Code
|
HCPCS 86160
|
| Hospital Charge Code |
4086160
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$47.60 |
| Max. Negotiated Rate |
$68.00 |
| Rate for Payer: Aetna Commercial |
$64.60
|
| Rate for Payer: Aetna Medicare |
$61.20
|
| Rate for Payer: BCBS MT CHIP |
$61.20
|
| Rate for Payer: BCBS MT Closed Plan Network |
$64.60
|
| Rate for Payer: BCBS MT HealthLink |
$61.20
|
| Rate for Payer: BCBS MT Medicare |
$61.20
|
| Rate for Payer: BCBS MT POS |
$64.60
|
| Rate for Payer: BCBS MT Traditional |
$68.00
|
| Rate for Payer: Cash Price |
$61.20
|
| Rate for Payer: Cigna Commercial |
$64.60
|
| Rate for Payer: Cigna Medicare |
$61.20
|
| Rate for Payer: Medicaid All Medicaid |
$62.56
|
| Rate for Payer: Medicare All Medicare |
$47.60
|
| Rate for Payer: Monida Allegiance |
$64.60
|
| Rate for Payer: Monida First Choice Health |
$65.96
|
| Rate for Payer: Monida Montana Health Co-op |
$64.60
|
| Rate for Payer: Monida PacificSource |
$64.60
|
|
|
COMPLEMENT C3 (006452)
|
Facility
|
IP
|
$68.00
|
|
|
Service Code
|
HCPCS 86160
|
| Hospital Charge Code |
4000051
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$47.60 |
| Max. Negotiated Rate |
$68.00 |
| Rate for Payer: Aetna Commercial |
$64.60
|
| Rate for Payer: Aetna Medicare |
$61.20
|
| Rate for Payer: BCBS MT CHIP |
$61.20
|
| Rate for Payer: BCBS MT Closed Plan Network |
$64.60
|
| Rate for Payer: BCBS MT HealthLink |
$61.20
|
| Rate for Payer: BCBS MT Medicare |
$61.20
|
| Rate for Payer: BCBS MT POS |
$64.60
|
| Rate for Payer: BCBS MT Traditional |
$68.00
|
| Rate for Payer: Cash Price |
$61.20
|
| Rate for Payer: Cigna Commercial |
$64.60
|
| Rate for Payer: Cigna Medicare |
$61.20
|
| Rate for Payer: Medicaid All Medicaid |
$62.56
|
| Rate for Payer: Medicare All Medicare |
$47.60
|
| Rate for Payer: Monida Allegiance |
$64.60
|
| Rate for Payer: Monida First Choice Health |
$65.96
|
| Rate for Payer: Monida Montana Health Co-op |
$64.60
|
| Rate for Payer: Monida PacificSource |
$64.60
|
|
|
COMPLEMENT C3 (006452)
|
Facility
|
OP
|
$68.00
|
|
|
Service Code
|
HCPCS 86160
|
| Hospital Charge Code |
4000051
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$47.60 |
| Max. Negotiated Rate |
$68.00 |
| Rate for Payer: Aetna Commercial |
$64.60
|
| Rate for Payer: Aetna Medicare |
$61.20
|
| Rate for Payer: BCBS MT CHIP |
$61.20
|
| Rate for Payer: BCBS MT Closed Plan Network |
$64.60
|
| Rate for Payer: BCBS MT HealthLink |
$61.20
|
| Rate for Payer: BCBS MT Medicare |
$61.20
|
| Rate for Payer: BCBS MT POS |
$64.60
|
| Rate for Payer: BCBS MT Traditional |
$68.00
|
| Rate for Payer: Cash Price |
$61.20
|
| Rate for Payer: Cigna Commercial |
$64.60
|
| Rate for Payer: Cigna Medicare |
$61.20
|
| Rate for Payer: Medicaid All Medicaid |
$62.56
|
| Rate for Payer: Medicare All Medicare |
$47.60
|
| Rate for Payer: Monida Allegiance |
$64.60
|
| Rate for Payer: Monida First Choice Health |
$65.96
|
| Rate for Payer: Monida Montana Health Co-op |
$64.60
|
| Rate for Payer: Monida PacificSource |
$64.60
|
|
|
COMPLEMENT C4 (001834)
|
Facility
|
OP
|
$68.00
|
|
|
Service Code
|
HCPCS 86160
|
| Hospital Charge Code |
4000052
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$47.60 |
| Max. Negotiated Rate |
$68.00 |
| Rate for Payer: Aetna Commercial |
$64.60
|
| Rate for Payer: Aetna Medicare |
$61.20
|
| Rate for Payer: BCBS MT CHIP |
$61.20
|
| Rate for Payer: BCBS MT Closed Plan Network |
$64.60
|
| Rate for Payer: BCBS MT HealthLink |
$61.20
|
| Rate for Payer: BCBS MT Medicare |
$61.20
|
| Rate for Payer: BCBS MT POS |
$64.60
|
| Rate for Payer: BCBS MT Traditional |
$68.00
|
| Rate for Payer: Cash Price |
$61.20
|
| Rate for Payer: Cigna Commercial |
$64.60
|
| Rate for Payer: Cigna Medicare |
$61.20
|
| Rate for Payer: Medicaid All Medicaid |
$62.56
|
| Rate for Payer: Medicare All Medicare |
$47.60
|
| Rate for Payer: Monida Allegiance |
$64.60
|
| Rate for Payer: Monida First Choice Health |
$65.96
|
| Rate for Payer: Monida Montana Health Co-op |
$64.60
|
| Rate for Payer: Monida PacificSource |
$64.60
|
|
|
COMPLEMENT C4 (001834)
|
Facility
|
IP
|
$68.00
|
|
|
Service Code
|
HCPCS 86160
|
| Hospital Charge Code |
4000052
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$47.60 |
| Max. Negotiated Rate |
$68.00 |
| Rate for Payer: Aetna Commercial |
$64.60
|
| Rate for Payer: Aetna Medicare |
$61.20
|
| Rate for Payer: BCBS MT CHIP |
$61.20
|
| Rate for Payer: BCBS MT Closed Plan Network |
$64.60
|
| Rate for Payer: BCBS MT HealthLink |
$61.20
|
| Rate for Payer: BCBS MT Medicare |
$61.20
|
| Rate for Payer: BCBS MT POS |
$64.60
|
| Rate for Payer: BCBS MT Traditional |
$68.00
|
| Rate for Payer: Cash Price |
$61.20
|
| Rate for Payer: Cigna Commercial |
$64.60
|
| Rate for Payer: Cigna Medicare |
$61.20
|
| Rate for Payer: Medicaid All Medicaid |
$62.56
|
| Rate for Payer: Medicare All Medicare |
$47.60
|
| Rate for Payer: Monida Allegiance |
$64.60
|
| Rate for Payer: Monida First Choice Health |
$65.96
|
| Rate for Payer: Monida Montana Health Co-op |
$64.60
|
| Rate for Payer: Monida PacificSource |
$64.60
|
|
|
COMPLEMENT, TOTAL (001941)
|
Facility
|
IP
|
$78.00
|
|
|
Service Code
|
HCPCS 86162
|
| Hospital Charge Code |
4086162
|
|
Hospital Revenue Code
|
302
|
| 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
|
|
|
COMPLEMENT, TOTAL (001941)
|
Facility
|
OP
|
$78.00
|
|
|
Service Code
|
HCPCS 86162
|
| Hospital Charge Code |
4086162
|
|
Hospital Revenue Code
|
302
|
| 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
|
|
|
.COMPLETE BLOOD COUNT, WITH AUTO DIFF
|
Facility
|
IP
|
$107.00
|
|
|
Service Code
|
HCPCS 85025
|
| Hospital Charge Code |
4085024
|
|
Hospital Revenue Code
|
305
|
| Min. Negotiated Rate |
$74.90 |
| Max. Negotiated Rate |
$107.00 |
| Rate for Payer: Aetna Commercial |
$101.65
|
| Rate for Payer: Aetna Medicare |
$96.30
|
| Rate for Payer: BCBS MT CHIP |
$96.30
|
| Rate for Payer: BCBS MT Closed Plan Network |
$101.65
|
| Rate for Payer: BCBS MT HealthLink |
$96.30
|
| Rate for Payer: BCBS MT Medicare |
$96.30
|
| Rate for Payer: BCBS MT POS |
$101.65
|
| Rate for Payer: BCBS MT Traditional |
$107.00
|
| Rate for Payer: Cash Price |
$96.30
|
| Rate for Payer: Cigna Commercial |
$101.65
|
| Rate for Payer: Cigna Medicare |
$96.30
|
| Rate for Payer: Medicaid All Medicaid |
$98.44
|
| Rate for Payer: Medicare All Medicare |
$74.90
|
| Rate for Payer: Monida Allegiance |
$101.65
|
| Rate for Payer: Monida First Choice Health |
$103.79
|
| Rate for Payer: Monida Montana Health Co-op |
$101.65
|
| Rate for Payer: Monida PacificSource |
$101.65
|
|
