|
CHRONIC CARE MGMT ADD'T 30 MIN COMPLEX
|
Facility
|
IP
|
$195.00
|
|
|
Service Code
|
CPT 99489
|
| Hospital Charge Code |
8099489
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$136.50 |
| Max. Negotiated Rate |
$195.00 |
| Rate for Payer: Aetna Commercial |
$185.25
|
| Rate for Payer: Aetna Medicare |
$175.50
|
| Rate for Payer: BCBS MT CHIP |
$175.50
|
| Rate for Payer: BCBS MT Closed Plan Network |
$185.25
|
| Rate for Payer: BCBS MT HealthLink |
$175.50
|
| Rate for Payer: BCBS MT Medicare |
$175.50
|
| Rate for Payer: BCBS MT POS |
$185.25
|
| Rate for Payer: BCBS MT Traditional |
$195.00
|
| Rate for Payer: Cash Price |
$175.50
|
| Rate for Payer: Cigna Commercial |
$185.25
|
| Rate for Payer: Cigna Medicare |
$175.50
|
| Rate for Payer: Medicaid All Medicaid |
$179.40
|
| Rate for Payer: Medicare All Medicare |
$136.50
|
| Rate for Payer: Monida Allegiance |
$185.25
|
| Rate for Payer: Monida First Choice Health |
$189.15
|
| Rate for Payer: Monida Montana Health Co-op |
$185.25
|
| Rate for Payer: Monida PacificSource |
$185.25
|
|
|
CHRONIC CARE MGMT ADD'T 30 MIN COMPLEX
|
Facility
|
OP
|
$195.00
|
|
|
Service Code
|
CPT 99489
|
| Hospital Charge Code |
8099489
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$136.50 |
| Max. Negotiated Rate |
$195.00 |
| Rate for Payer: Aetna Commercial |
$185.25
|
| Rate for Payer: Aetna Medicare |
$175.50
|
| Rate for Payer: BCBS MT CHIP |
$175.50
|
| Rate for Payer: BCBS MT Closed Plan Network |
$185.25
|
| Rate for Payer: BCBS MT HealthLink |
$175.50
|
| Rate for Payer: BCBS MT Medicare |
$175.50
|
| Rate for Payer: BCBS MT POS |
$185.25
|
| Rate for Payer: BCBS MT Traditional |
$195.00
|
| Rate for Payer: Cash Price |
$175.50
|
| Rate for Payer: Cigna Commercial |
$185.25
|
| Rate for Payer: Cigna Medicare |
$175.50
|
| Rate for Payer: Medicaid All Medicaid |
$179.40
|
| Rate for Payer: Medicare All Medicare |
$136.50
|
| Rate for Payer: Monida Allegiance |
$185.25
|
| Rate for Payer: Monida First Choice Health |
$189.15
|
| Rate for Payer: Monida Montana Health Co-op |
$185.25
|
| Rate for Payer: Monida PacificSource |
$185.25
|
|
|
CHUX (BLUE)
|
Facility
|
OP
|
$4.00
|
|
| Hospital Charge Code |
80030310
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$2.80 |
| Max. Negotiated Rate |
$4.00 |
| Rate for Payer: Aetna Commercial |
$3.80
|
| Rate for Payer: Aetna Medicare |
$3.60
|
| Rate for Payer: BCBS MT CHIP |
$3.60
|
| Rate for Payer: BCBS MT Closed Plan Network |
$3.80
|
| Rate for Payer: BCBS MT HealthLink |
$3.60
|
| Rate for Payer: BCBS MT Medicare |
$3.60
|
| Rate for Payer: BCBS MT POS |
$3.80
|
| Rate for Payer: BCBS MT Traditional |
$4.00
|
| Rate for Payer: Cash Price |
$3.60
|
| Rate for Payer: Cigna Commercial |
$3.80
|
| Rate for Payer: Cigna Medicare |
$3.60
|
| Rate for Payer: Medicaid All Medicaid |
$3.68
|
| Rate for Payer: Medicare All Medicare |
$2.80
|
| Rate for Payer: Monida Allegiance |
$3.80
|
| Rate for Payer: Monida First Choice Health |
$3.88
|
| Rate for Payer: Monida Montana Health Co-op |
$3.80
|
| Rate for Payer: Monida PacificSource |
$3.80
|
|
|
CHUX (BLUE)
|
Facility
|
IP
|
$4.00
|
|
| Hospital Charge Code |
80030310
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$2.80 |
| Max. Negotiated Rate |
$4.00 |
| Rate for Payer: Aetna Commercial |
$3.80
|
| Rate for Payer: Aetna Medicare |
$3.60
|
| Rate for Payer: BCBS MT CHIP |
$3.60
|
| Rate for Payer: BCBS MT Closed Plan Network |
$3.80
|
| Rate for Payer: BCBS MT HealthLink |
$3.60
|
| Rate for Payer: BCBS MT Medicare |
$3.60
|
| Rate for Payer: BCBS MT POS |
$3.80
|
| Rate for Payer: BCBS MT Traditional |
$4.00
|
| Rate for Payer: Cash Price |
$3.60
|
| Rate for Payer: Cigna Commercial |
$3.80
|
| Rate for Payer: Cigna Medicare |
$3.60
|
| Rate for Payer: Medicaid All Medicaid |
$3.68
|
| Rate for Payer: Medicare All Medicare |
$2.80
|
| Rate for Payer: Monida Allegiance |
$3.80
|
| Rate for Payer: Monida First Choice Health |
$3.88
|
| Rate for Payer: Monida Montana Health Co-op |
$3.80
|
| Rate for Payer: Monida PacificSource |
$3.80
|
|
|
CHUX (WHITE)
|
Facility
|
IP
|
$20.00
|
|
| Hospital Charge Code |
80030103
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$14.00 |
| Max. Negotiated Rate |
$20.00 |
| Rate for Payer: Aetna Commercial |
$19.00
|
| Rate for Payer: Aetna Medicare |
$18.00
|
| Rate for Payer: BCBS MT CHIP |
$18.00
|
| Rate for Payer: BCBS MT Closed Plan Network |
$19.00
|
| Rate for Payer: BCBS MT HealthLink |
$18.00
|
| Rate for Payer: BCBS MT Medicare |
$18.00
|
| Rate for Payer: BCBS MT POS |
$19.00
|
| Rate for Payer: BCBS MT Traditional |
$20.00
|
| Rate for Payer: Cash Price |
$18.00
|
| Rate for Payer: Cigna Commercial |
$19.00
|
| Rate for Payer: Cigna Medicare |
$18.00
|
| Rate for Payer: Medicaid All Medicaid |
$18.40
|
| Rate for Payer: Medicare All Medicare |
$14.00
|
| Rate for Payer: Monida Allegiance |
$19.00
|
| Rate for Payer: Monida First Choice Health |
$19.40
|
| Rate for Payer: Monida Montana Health Co-op |
$19.00
|
| Rate for Payer: Monida PacificSource |
$19.00
|
|
|
CHUX (WHITE)
|
Facility
|
OP
|
$20.00
|
|
| Hospital Charge Code |
80030103
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$14.00 |
| Max. Negotiated Rate |
$20.00 |
| Rate for Payer: Aetna Commercial |
$19.00
|
| Rate for Payer: Aetna Medicare |
$18.00
|
| Rate for Payer: BCBS MT CHIP |
$18.00
|
| Rate for Payer: BCBS MT Closed Plan Network |
$19.00
|
| Rate for Payer: BCBS MT HealthLink |
$18.00
|
| Rate for Payer: BCBS MT Medicare |
$18.00
|
| Rate for Payer: BCBS MT POS |
$19.00
|
| Rate for Payer: BCBS MT Traditional |
$20.00
|
| Rate for Payer: Cash Price |
$18.00
|
| Rate for Payer: Cigna Commercial |
$19.00
|
| Rate for Payer: Cigna Medicare |
$18.00
|
| Rate for Payer: Medicaid All Medicaid |
$18.40
|
| Rate for Payer: Medicare All Medicare |
$14.00
|
| Rate for Payer: Monida Allegiance |
$19.00
|
| Rate for Payer: Monida First Choice Health |
$19.40
|
| Rate for Payer: Monida Montana Health Co-op |
$19.00
|
| Rate for Payer: Monida PacificSource |
$19.00
|
|
|
CILOSTAZOL TAB [50 MG] NF
|
Facility
|
OP
|
$8.00
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
3000088
|
|
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
|
|
|
CILOSTAZOL TAB [50 MG] NF
|
Facility
|
IP
|
$8.00
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
3000088
|
|
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
|
|
|
CIPRO/DEXAMETH OTIC [0.3% / 0.1%] NF
|
Facility
|
OP
|
$644.50
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
3000089
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$451.15 |
| Max. Negotiated Rate |
$644.50 |
| Rate for Payer: Aetna Commercial |
$612.27
|
| Rate for Payer: Aetna Medicare |
$580.05
|
| Rate for Payer: BCBS MT CHIP |
$580.05
|
| Rate for Payer: BCBS MT Closed Plan Network |
$612.27
|
| Rate for Payer: BCBS MT HealthLink |
$580.05
|
| Rate for Payer: BCBS MT Medicare |
$580.05
|
| Rate for Payer: BCBS MT POS |
$612.27
|
| Rate for Payer: BCBS MT Traditional |
$644.50
|
| Rate for Payer: Cash Price |
$580.05
|
| Rate for Payer: Cigna Commercial |
$612.27
|
| Rate for Payer: Cigna Medicare |
$580.05
|
| Rate for Payer: Medicaid All Medicaid |
$592.94
|
| Rate for Payer: Medicare All Medicare |
$451.15
|
| Rate for Payer: Monida Allegiance |
$612.27
|
| Rate for Payer: Monida First Choice Health |
$625.16
|
| Rate for Payer: Monida Montana Health Co-op |
$612.27
|
| Rate for Payer: Monida PacificSource |
$612.27
|
|
|
CIPRO/DEXAMETH OTIC [0.3% / 0.1%] NF
|
Facility
|
IP
|
$644.50
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
3000089
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$451.15 |
| Max. Negotiated Rate |
$644.50 |
| Rate for Payer: Aetna Commercial |
$612.27
|
| Rate for Payer: Aetna Medicare |
$580.05
|
| Rate for Payer: BCBS MT CHIP |
$580.05
|
| Rate for Payer: BCBS MT Closed Plan Network |
$612.27
|
| Rate for Payer: BCBS MT HealthLink |
$580.05
|
| Rate for Payer: BCBS MT Medicare |
$580.05
|
| Rate for Payer: BCBS MT POS |
$612.27
|
| Rate for Payer: BCBS MT Traditional |
$644.50
|
| Rate for Payer: Cash Price |
$580.05
|
| Rate for Payer: Cigna Commercial |
$612.27
|
| Rate for Payer: Cigna Medicare |
$580.05
|
| Rate for Payer: Medicaid All Medicaid |
$592.94
|
| Rate for Payer: Medicare All Medicare |
$451.15
|
| Rate for Payer: Monida Allegiance |
$612.27
|
| Rate for Payer: Monida First Choice Health |
$625.16
|
| Rate for Payer: Monida Montana Health Co-op |
$612.27
|
| Rate for Payer: Monida PacificSource |
$612.27
|
|
|
CIPROFLOXACIN TAB [250 MG] NF
|
Facility
|
OP
|
$15.00
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
3000091
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.50 |
| Max. Negotiated Rate |
$15.00 |
| Rate for Payer: Aetna Commercial |
$14.25
|
| Rate for Payer: Aetna Medicare |
$13.50
|
| Rate for Payer: BCBS MT CHIP |
$13.50
|
| Rate for Payer: BCBS MT Closed Plan Network |
$14.25
|
| Rate for Payer: BCBS MT HealthLink |
$13.50
|
| Rate for Payer: BCBS MT Medicare |
$13.50
|
| Rate for Payer: BCBS MT POS |
$14.25
|
| Rate for Payer: BCBS MT Traditional |
$15.00
|
| Rate for Payer: Cash Price |
$13.50
|
| Rate for Payer: Cigna Commercial |
$14.25
|
| Rate for Payer: Cigna Medicare |
$13.50
|
| Rate for Payer: Medicaid All Medicaid |
$13.80
|
| Rate for Payer: Medicare All Medicare |
$10.50
|
| Rate for Payer: Monida Allegiance |
$14.25
|
| Rate for Payer: Monida First Choice Health |
$14.55
|
| Rate for Payer: Monida Montana Health Co-op |
$14.25
|
| Rate for Payer: Monida PacificSource |
$14.25
|
|
|
CIPROFLOXACIN TAB [250 MG] NF
|
Facility
|
IP
|
$15.00
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
3000091
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.50 |
| Max. Negotiated Rate |
$15.00 |
| Rate for Payer: Aetna Commercial |
$14.25
|
| Rate for Payer: Aetna Medicare |
$13.50
|
| Rate for Payer: BCBS MT CHIP |
$13.50
|
| Rate for Payer: BCBS MT Closed Plan Network |
$14.25
|
| Rate for Payer: BCBS MT HealthLink |
$13.50
|
| Rate for Payer: BCBS MT Medicare |
$13.50
|
| Rate for Payer: BCBS MT POS |
$14.25
|
| Rate for Payer: BCBS MT Traditional |
$15.00
|
| Rate for Payer: Cash Price |
$13.50
|
| Rate for Payer: Cigna Commercial |
$14.25
|
| Rate for Payer: Cigna Medicare |
$13.50
|
| Rate for Payer: Medicaid All Medicaid |
$13.80
|
| Rate for Payer: Medicare All Medicare |
$10.50
|
| Rate for Payer: Monida Allegiance |
$14.25
|
| Rate for Payer: Monida First Choice Health |
$14.55
|
| Rate for Payer: Monida Montana Health Co-op |
$14.25
|
| Rate for Payer: Monida PacificSource |
$14.25
|
|
|
CIPROFLOXACIN TAB [500 MG]
|
Facility
|
OP
|
$8.00
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
3000092
|
|
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
|
|
|
CIPROFLOXACIN TAB [500 MG]
|
Facility
|
IP
|
$8.00
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
3000092
|
|
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
|
|
|
CIRCUMCISION W/CLAMP/OTH DEV W/BLOCK
|
Facility
|
OP
|
$350.00
|
|
|
Service Code
|
CPT 54150
|
| Hospital Charge Code |
354150
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$245.00 |
| Max. Negotiated Rate |
$350.00 |
| Rate for Payer: Aetna Commercial |
$332.50
|
| Rate for Payer: Aetna Medicare |
$315.00
|
| Rate for Payer: BCBS MT CHIP |
$315.00
|
| Rate for Payer: BCBS MT Closed Plan Network |
$332.50
|
| Rate for Payer: BCBS MT HealthLink |
$315.00
|
| Rate for Payer: BCBS MT Medicare |
$315.00
|
| Rate for Payer: BCBS MT POS |
$332.50
|
| Rate for Payer: BCBS MT Traditional |
$350.00
|
| Rate for Payer: Cash Price |
$315.00
|
| Rate for Payer: Cigna Commercial |
$332.50
|
| Rate for Payer: Cigna Medicare |
$315.00
|
| Rate for Payer: Medicaid All Medicaid |
$322.00
|
| Rate for Payer: Medicare All Medicare |
$245.00
|
| Rate for Payer: Monida Allegiance |
$332.50
|
| Rate for Payer: Monida First Choice Health |
$339.50
|
| Rate for Payer: Monida Montana Health Co-op |
$332.50
|
| Rate for Payer: Monida PacificSource |
$332.50
|
|
|
CIRCUMCISION W/CLAMP/OTH DEV W/BLOCK
|
Facility
|
IP
|
$350.00
|
|
|
Service Code
|
CPT 54150
|
| Hospital Charge Code |
8054150
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$245.00 |
| Max. Negotiated Rate |
$350.00 |
| Rate for Payer: Aetna Commercial |
$332.50
|
| Rate for Payer: Aetna Medicare |
$315.00
|
| Rate for Payer: BCBS MT CHIP |
$315.00
|
| Rate for Payer: BCBS MT Closed Plan Network |
$332.50
|
| Rate for Payer: BCBS MT HealthLink |
$315.00
|
| Rate for Payer: BCBS MT Medicare |
$315.00
|
| Rate for Payer: BCBS MT POS |
$332.50
|
| Rate for Payer: BCBS MT Traditional |
$350.00
|
| Rate for Payer: Cash Price |
$315.00
|
| Rate for Payer: Cigna Commercial |
$332.50
|
| Rate for Payer: Cigna Medicare |
$315.00
|
| Rate for Payer: Medicaid All Medicaid |
$322.00
|
| Rate for Payer: Medicare All Medicare |
$245.00
|
| Rate for Payer: Monida Allegiance |
$332.50
|
| Rate for Payer: Monida First Choice Health |
$339.50
|
| Rate for Payer: Monida Montana Health Co-op |
$332.50
|
| Rate for Payer: Monida PacificSource |
$332.50
|
|
|
CIRCUMCISION W/CLAMP/OTH DEV W/BLOCK
|
Facility
|
OP
|
$350.00
|
|
|
Service Code
|
CPT 54150
|
| Hospital Charge Code |
8054150
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$245.00 |
| Max. Negotiated Rate |
$350.00 |
| Rate for Payer: Aetna Commercial |
$332.50
|
| Rate for Payer: Aetna Medicare |
$315.00
|
| Rate for Payer: BCBS MT CHIP |
$315.00
|
| Rate for Payer: BCBS MT Closed Plan Network |
$332.50
|
| Rate for Payer: BCBS MT HealthLink |
$315.00
|
| Rate for Payer: BCBS MT Medicare |
$315.00
|
| Rate for Payer: BCBS MT POS |
$332.50
|
| Rate for Payer: BCBS MT Traditional |
$350.00
|
| Rate for Payer: Cash Price |
$315.00
|
| Rate for Payer: Cigna Commercial |
$332.50
|
| Rate for Payer: Cigna Medicare |
$315.00
|
| Rate for Payer: Medicaid All Medicaid |
$322.00
|
| Rate for Payer: Medicare All Medicare |
$245.00
|
| Rate for Payer: Monida Allegiance |
$332.50
|
| Rate for Payer: Monida First Choice Health |
$339.50
|
| Rate for Payer: Monida Montana Health Co-op |
$332.50
|
| Rate for Payer: Monida PacificSource |
$332.50
|
|
|
CIRCUMCISION W/CLAMP/OTH DEV W/BLOCK
|
Facility
|
IP
|
$350.00
|
|
|
Service Code
|
CPT 54150
|
| Hospital Charge Code |
354150
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$245.00 |
| Max. Negotiated Rate |
$350.00 |
| Rate for Payer: Aetna Commercial |
$332.50
|
| Rate for Payer: Aetna Medicare |
$315.00
|
| Rate for Payer: BCBS MT CHIP |
$315.00
|
| Rate for Payer: BCBS MT Closed Plan Network |
$332.50
|
| Rate for Payer: BCBS MT HealthLink |
$315.00
|
| Rate for Payer: BCBS MT Medicare |
$315.00
|
| Rate for Payer: BCBS MT POS |
$332.50
|
| Rate for Payer: BCBS MT Traditional |
$350.00
|
| Rate for Payer: Cash Price |
$315.00
|
| Rate for Payer: Cigna Commercial |
$332.50
|
| Rate for Payer: Cigna Medicare |
$315.00
|
| Rate for Payer: Medicaid All Medicaid |
$322.00
|
| Rate for Payer: Medicare All Medicare |
$245.00
|
| Rate for Payer: Monida Allegiance |
$332.50
|
| Rate for Payer: Monida First Choice Health |
$339.50
|
| Rate for Payer: Monida Montana Health Co-op |
$332.50
|
| Rate for Payer: Monida PacificSource |
$332.50
|
|
|
CITALOPRAM TAB [20 MG]
|
Facility
|
OP
|
$9.00
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
3000093
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.30 |
| Max. Negotiated Rate |
$9.00 |
| Rate for Payer: Aetna Commercial |
$8.55
|
| Rate for Payer: Aetna Medicare |
$8.10
|
| Rate for Payer: BCBS MT CHIP |
$8.10
|
| Rate for Payer: BCBS MT Closed Plan Network |
$8.55
|
| Rate for Payer: BCBS MT HealthLink |
$8.10
|
| Rate for Payer: BCBS MT Medicare |
$8.10
|
| Rate for Payer: BCBS MT POS |
$8.55
|
| Rate for Payer: BCBS MT Traditional |
$9.00
|
| Rate for Payer: Cash Price |
$8.10
|
| Rate for Payer: Cigna Commercial |
$8.55
|
| Rate for Payer: Cigna Medicare |
$8.10
|
| Rate for Payer: Medicaid All Medicaid |
$8.28
|
| Rate for Payer: Medicare All Medicare |
$6.30
|
| Rate for Payer: Monida Allegiance |
$8.55
|
| Rate for Payer: Monida First Choice Health |
$8.73
|
| Rate for Payer: Monida Montana Health Co-op |
$8.55
|
| Rate for Payer: Monida PacificSource |
$8.55
|
|
|
CITALOPRAM TAB [20 MG]
|
Facility
|
IP
|
$9.00
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
3000093
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.30 |
| Max. Negotiated Rate |
$9.00 |
| Rate for Payer: Aetna Commercial |
$8.55
|
| Rate for Payer: Aetna Medicare |
$8.10
|
| Rate for Payer: BCBS MT CHIP |
$8.10
|
| Rate for Payer: BCBS MT Closed Plan Network |
$8.55
|
| Rate for Payer: BCBS MT HealthLink |
$8.10
|
| Rate for Payer: BCBS MT Medicare |
$8.10
|
| Rate for Payer: BCBS MT POS |
$8.55
|
| Rate for Payer: BCBS MT Traditional |
$9.00
|
| Rate for Payer: Cash Price |
$8.10
|
| Rate for Payer: Cigna Commercial |
$8.55
|
| Rate for Payer: Cigna Medicare |
$8.10
|
| Rate for Payer: Medicaid All Medicaid |
$8.28
|
| Rate for Payer: Medicare All Medicare |
$6.30
|
| Rate for Payer: Monida Allegiance |
$8.55
|
| Rate for Payer: Monida First Choice Health |
$8.73
|
| Rate for Payer: Monida Montana Health Co-op |
$8.55
|
| Rate for Payer: Monida PacificSource |
$8.55
|
|
|
CITRACAL TAB [650 MG/1000 IU] NF
|
Facility
|
IP
|
$5.00
|
|
| Hospital Charge Code |
3000624
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.50 |
| Max. Negotiated Rate |
$5.00 |
| Rate for Payer: Aetna Commercial |
$4.75
|
| Rate for Payer: Aetna Medicare |
$4.50
|
| Rate for Payer: BCBS MT CHIP |
$4.50
|
| Rate for Payer: BCBS MT Closed Plan Network |
$4.75
|
| Rate for Payer: BCBS MT HealthLink |
$4.50
|
| Rate for Payer: BCBS MT Medicare |
$4.50
|
| Rate for Payer: BCBS MT POS |
$4.75
|
| Rate for Payer: BCBS MT Traditional |
$5.00
|
| Rate for Payer: Cash Price |
$4.50
|
| Rate for Payer: Cigna Commercial |
$4.75
|
| Rate for Payer: Cigna Medicare |
$4.50
|
| Rate for Payer: Medicaid All Medicaid |
$4.60
|
| Rate for Payer: Medicare All Medicare |
$3.50
|
| Rate for Payer: Monida Allegiance |
$4.75
|
| Rate for Payer: Monida First Choice Health |
$4.85
|
| Rate for Payer: Monida Montana Health Co-op |
$4.75
|
| Rate for Payer: Monida PacificSource |
$4.75
|
|
|
CITRACAL TAB [650 MG/1000 IU] NF
|
Facility
|
OP
|
$5.00
|
|
| Hospital Charge Code |
3000624
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.50 |
| Max. Negotiated Rate |
$5.00 |
| Rate for Payer: Aetna Commercial |
$4.75
|
| Rate for Payer: Aetna Medicare |
$4.50
|
| Rate for Payer: BCBS MT CHIP |
$4.50
|
| Rate for Payer: BCBS MT Closed Plan Network |
$4.75
|
| Rate for Payer: BCBS MT HealthLink |
$4.50
|
| Rate for Payer: BCBS MT Medicare |
$4.50
|
| Rate for Payer: BCBS MT POS |
$4.75
|
| Rate for Payer: BCBS MT Traditional |
$5.00
|
| Rate for Payer: Cash Price |
$4.50
|
| Rate for Payer: Cigna Commercial |
$4.75
|
| Rate for Payer: Cigna Medicare |
$4.50
|
| Rate for Payer: Medicaid All Medicaid |
$4.60
|
| Rate for Payer: Medicare All Medicare |
$3.50
|
| Rate for Payer: Monida Allegiance |
$4.75
|
| Rate for Payer: Monida First Choice Health |
$4.85
|
| Rate for Payer: Monida Montana Health Co-op |
$4.75
|
| Rate for Payer: Monida PacificSource |
$4.75
|
|
|
.CITRATE URINE
|
Facility
|
OP
|
$20.00
|
|
|
Service Code
|
CPT 82507
|
| Hospital Charge Code |
4088152
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$14.00 |
| Max. Negotiated Rate |
$20.00 |
| Rate for Payer: Aetna Commercial |
$19.00
|
| Rate for Payer: Aetna Medicare |
$18.00
|
| Rate for Payer: BCBS MT CHIP |
$18.00
|
| Rate for Payer: BCBS MT Closed Plan Network |
$19.00
|
| Rate for Payer: BCBS MT HealthLink |
$18.00
|
| Rate for Payer: BCBS MT Medicare |
$18.00
|
| Rate for Payer: BCBS MT POS |
$19.00
|
| Rate for Payer: BCBS MT Traditional |
$20.00
|
| Rate for Payer: Cash Price |
$18.00
|
| Rate for Payer: Cigna Commercial |
$19.00
|
| Rate for Payer: Cigna Medicare |
$18.00
|
| Rate for Payer: Medicaid All Medicaid |
$18.40
|
| Rate for Payer: Medicare All Medicare |
$14.00
|
| Rate for Payer: Monida Allegiance |
$19.00
|
| Rate for Payer: Monida First Choice Health |
$19.40
|
| Rate for Payer: Monida Montana Health Co-op |
$19.00
|
| Rate for Payer: Monida PacificSource |
$19.00
|
|
|
.CITRATE URINE
|
Facility
|
IP
|
$20.00
|
|
|
Service Code
|
CPT 82507
|
| Hospital Charge Code |
4088152
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$14.00 |
| Max. Negotiated Rate |
$20.00 |
| Rate for Payer: Aetna Commercial |
$19.00
|
| Rate for Payer: Aetna Medicare |
$18.00
|
| Rate for Payer: BCBS MT CHIP |
$18.00
|
| Rate for Payer: BCBS MT Closed Plan Network |
$19.00
|
| Rate for Payer: BCBS MT HealthLink |
$18.00
|
| Rate for Payer: BCBS MT Medicare |
$18.00
|
| Rate for Payer: BCBS MT POS |
$19.00
|
| Rate for Payer: BCBS MT Traditional |
$20.00
|
| Rate for Payer: Cash Price |
$18.00
|
| Rate for Payer: Cigna Commercial |
$19.00
|
| Rate for Payer: Cigna Medicare |
$18.00
|
| Rate for Payer: Medicaid All Medicaid |
$18.40
|
| Rate for Payer: Medicare All Medicare |
$14.00
|
| Rate for Payer: Monida Allegiance |
$19.00
|
| Rate for Payer: Monida First Choice Health |
$19.40
|
| Rate for Payer: Monida Montana Health Co-op |
$19.00
|
| Rate for Payer: Monida PacificSource |
$19.00
|
|
|
CKI/MBI CALIBRATOR DC32 2 X
|
Facility
|
OP
|
$34.49
|
|
| Hospital Charge Code |
90195088
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$24.14 |
| Max. Negotiated Rate |
$34.49 |
| Rate for Payer: Aetna Commercial |
$32.77
|
| Rate for Payer: Aetna Medicare |
$31.04
|
| Rate for Payer: BCBS MT CHIP |
$31.04
|
| Rate for Payer: BCBS MT Closed Plan Network |
$32.77
|
| Rate for Payer: BCBS MT HealthLink |
$31.04
|
| Rate for Payer: BCBS MT Medicare |
$31.04
|
| Rate for Payer: BCBS MT POS |
$32.77
|
| Rate for Payer: BCBS MT Traditional |
$34.49
|
| Rate for Payer: Cash Price |
$31.04
|
| Rate for Payer: Cigna Commercial |
$32.77
|
| Rate for Payer: Cigna Medicare |
$31.04
|
| Rate for Payer: Medicaid All Medicaid |
$31.73
|
| Rate for Payer: Medicare All Medicare |
$24.14
|
| Rate for Payer: Monida Allegiance |
$32.77
|
| Rate for Payer: Monida First Choice Health |
$33.46
|
| Rate for Payer: Monida Montana Health Co-op |
$32.77
|
| Rate for Payer: Monida PacificSource |
$32.77
|
|
