|
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
|
|
|
CKMB (120816)
|
Facility
|
OP
|
$200.00
|
|
|
Service Code
|
CPT 82553
|
| Hospital Charge Code |
4082553
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$140.00 |
| Max. Negotiated Rate |
$200.00 |
| Rate for Payer: Aetna Commercial |
$190.00
|
| Rate for Payer: Aetna Medicare |
$180.00
|
| Rate for Payer: BCBS MT CHIP |
$180.00
|
| Rate for Payer: BCBS MT Closed Plan Network |
$190.00
|
| Rate for Payer: BCBS MT HealthLink |
$180.00
|
| Rate for Payer: BCBS MT Medicare |
$180.00
|
| Rate for Payer: BCBS MT POS |
$190.00
|
| Rate for Payer: BCBS MT Traditional |
$200.00
|
| Rate for Payer: Cash Price |
$180.00
|
| Rate for Payer: Cigna Commercial |
$190.00
|
| Rate for Payer: Cigna Medicare |
$180.00
|
| Rate for Payer: Medicaid All Medicaid |
$184.00
|
| Rate for Payer: Medicare All Medicare |
$140.00
|
| Rate for Payer: Monida Allegiance |
$190.00
|
| Rate for Payer: Monida First Choice Health |
$194.00
|
| Rate for Payer: Monida Montana Health Co-op |
$190.00
|
| Rate for Payer: Monida PacificSource |
$190.00
|
|
|
CKMB (120816)
|
Facility
|
IP
|
$200.00
|
|
|
Service Code
|
CPT 82553
|
| Hospital Charge Code |
4082553
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$140.00 |
| Max. Negotiated Rate |
$200.00 |
| Rate for Payer: Aetna Commercial |
$190.00
|
| Rate for Payer: Aetna Medicare |
$180.00
|
| Rate for Payer: BCBS MT CHIP |
$180.00
|
| Rate for Payer: BCBS MT Closed Plan Network |
$190.00
|
| Rate for Payer: BCBS MT HealthLink |
$180.00
|
| Rate for Payer: BCBS MT Medicare |
$180.00
|
| Rate for Payer: BCBS MT POS |
$190.00
|
| Rate for Payer: BCBS MT Traditional |
$200.00
|
| Rate for Payer: Cash Price |
$180.00
|
| Rate for Payer: Cigna Commercial |
$190.00
|
| Rate for Payer: Cigna Medicare |
$180.00
|
| Rate for Payer: Medicaid All Medicaid |
$184.00
|
| Rate for Payer: Medicare All Medicare |
$140.00
|
| Rate for Payer: Monida Allegiance |
$190.00
|
| Rate for Payer: Monida First Choice Health |
$194.00
|
| Rate for Payer: Monida Montana Health Co-op |
$190.00
|
| Rate for Payer: Monida PacificSource |
$190.00
|
|
|
CLARITHROMYCIN 500MG TAB NF
|
Facility
|
OP
|
$20.00
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
3000094
|
|
Hospital Revenue Code
|
250
|
| 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
|
|
|
CLARITHROMYCIN 500MG TAB NF
|
Facility
|
IP
|
$20.00
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
3000094
|
|
Hospital Revenue Code
|
250
|
| 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
|
|
|
CLAVICAL SPLINT LG
|
Facility
|
OP
|
$21.00
|
|
| Hospital Charge Code |
2893266
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$14.70 |
| Max. Negotiated Rate |
$21.00 |
| Rate for Payer: Aetna Commercial |
$19.95
|
| Rate for Payer: Aetna Medicare |
$18.90
|
| Rate for Payer: BCBS MT CHIP |
$18.90
|
| Rate for Payer: BCBS MT Closed Plan Network |
$19.95
|
| Rate for Payer: BCBS MT HealthLink |
$18.90
|
| Rate for Payer: BCBS MT Medicare |
$18.90
|
| Rate for Payer: BCBS MT POS |
$19.95
|
| Rate for Payer: BCBS MT Traditional |
$21.00
|
| Rate for Payer: Cash Price |
$18.90
|
| Rate for Payer: Cigna Commercial |
$19.95
|
| Rate for Payer: Cigna Medicare |
$18.90
|
| Rate for Payer: Medicaid All Medicaid |
$19.32
|
| Rate for Payer: Medicare All Medicare |
$14.70
|
| Rate for Payer: Monida Allegiance |
$19.95
|
| Rate for Payer: Monida First Choice Health |
$20.37
|
| Rate for Payer: Monida Montana Health Co-op |
$19.95
|
| Rate for Payer: Monida PacificSource |
$19.95
|
|
|
CLAVICAL SPLINT LG
|
Facility
|
IP
|
$21.00
|
|
| Hospital Charge Code |
2893266
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$14.70 |
| Max. Negotiated Rate |
$21.00 |
| Rate for Payer: Aetna Commercial |
$19.95
|
| Rate for Payer: Aetna Medicare |
$18.90
|
| Rate for Payer: BCBS MT CHIP |
$18.90
|
| Rate for Payer: BCBS MT Closed Plan Network |
$19.95
|
| Rate for Payer: BCBS MT HealthLink |
$18.90
|
| Rate for Payer: BCBS MT Medicare |
$18.90
|
| Rate for Payer: BCBS MT POS |
$19.95
|
| Rate for Payer: BCBS MT Traditional |
$21.00
|
| Rate for Payer: Cash Price |
$18.90
|
| Rate for Payer: Cigna Commercial |
$19.95
|
| Rate for Payer: Cigna Medicare |
$18.90
|
| Rate for Payer: Medicaid All Medicaid |
$19.32
|
| Rate for Payer: Medicare All Medicare |
$14.70
|
| Rate for Payer: Monida Allegiance |
$19.95
|
| Rate for Payer: Monida First Choice Health |
$20.37
|
| Rate for Payer: Monida Montana Health Co-op |
$19.95
|
| Rate for Payer: Monida PacificSource |
$19.95
|
|
|
CLAVICAL SPLINT MD
|
Facility
|
OP
|
$21.00
|
|
| Hospital Charge Code |
2893265
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$14.70 |
| Max. Negotiated Rate |
$21.00 |
| Rate for Payer: Aetna Commercial |
$19.95
|
| Rate for Payer: Aetna Medicare |
$18.90
|
| Rate for Payer: BCBS MT CHIP |
$18.90
|
| Rate for Payer: BCBS MT Closed Plan Network |
$19.95
|
| Rate for Payer: BCBS MT HealthLink |
$18.90
|
| Rate for Payer: BCBS MT Medicare |
$18.90
|
| Rate for Payer: BCBS MT POS |
$19.95
|
| Rate for Payer: BCBS MT Traditional |
$21.00
|
| Rate for Payer: Cash Price |
$18.90
|
| Rate for Payer: Cigna Commercial |
$19.95
|
| Rate for Payer: Cigna Medicare |
$18.90
|
| Rate for Payer: Medicaid All Medicaid |
$19.32
|
| Rate for Payer: Medicare All Medicare |
$14.70
|
| Rate for Payer: Monida Allegiance |
$19.95
|
| Rate for Payer: Monida First Choice Health |
$20.37
|
| Rate for Payer: Monida Montana Health Co-op |
$19.95
|
| Rate for Payer: Monida PacificSource |
$19.95
|
|
|
CLAVICAL SPLINT MD
|
Facility
|
IP
|
$21.00
|
|
| Hospital Charge Code |
2893265
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$14.70 |
| Max. Negotiated Rate |
$21.00 |
| Rate for Payer: Aetna Commercial |
$19.95
|
| Rate for Payer: Aetna Medicare |
$18.90
|
| Rate for Payer: BCBS MT CHIP |
$18.90
|
| Rate for Payer: BCBS MT Closed Plan Network |
$19.95
|
| Rate for Payer: BCBS MT HealthLink |
$18.90
|
| Rate for Payer: BCBS MT Medicare |
$18.90
|
| Rate for Payer: BCBS MT POS |
$19.95
|
| Rate for Payer: BCBS MT Traditional |
$21.00
|
| Rate for Payer: Cash Price |
$18.90
|
| Rate for Payer: Cigna Commercial |
$19.95
|
| Rate for Payer: Cigna Medicare |
$18.90
|
| Rate for Payer: Medicaid All Medicaid |
$19.32
|
| Rate for Payer: Medicare All Medicare |
$14.70
|
| Rate for Payer: Monida Allegiance |
$19.95
|
| Rate for Payer: Monida First Choice Health |
$20.37
|
| Rate for Payer: Monida Montana Health Co-op |
$19.95
|
| Rate for Payer: Monida PacificSource |
$19.95
|
|
|
CLAVICAL SPLINT SM
|
Facility
|
OP
|
$21.00
|
|
| Hospital Charge Code |
2893264
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$14.70 |
| Max. Negotiated Rate |
$21.00 |
| Rate for Payer: Aetna Commercial |
$19.95
|
| Rate for Payer: Aetna Medicare |
$18.90
|
| Rate for Payer: BCBS MT CHIP |
$18.90
|
| Rate for Payer: BCBS MT Closed Plan Network |
$19.95
|
| Rate for Payer: BCBS MT HealthLink |
$18.90
|
| Rate for Payer: BCBS MT Medicare |
$18.90
|
| Rate for Payer: BCBS MT POS |
$19.95
|
| Rate for Payer: BCBS MT Traditional |
$21.00
|
| Rate for Payer: Cash Price |
$18.90
|
| Rate for Payer: Cigna Commercial |
$19.95
|
| Rate for Payer: Cigna Medicare |
$18.90
|
| Rate for Payer: Medicaid All Medicaid |
$19.32
|
| Rate for Payer: Medicare All Medicare |
$14.70
|
| Rate for Payer: Monida Allegiance |
$19.95
|
| Rate for Payer: Monida First Choice Health |
$20.37
|
| Rate for Payer: Monida Montana Health Co-op |
$19.95
|
| Rate for Payer: Monida PacificSource |
$19.95
|
|
|
CLAVICAL SPLINT SM
|
Facility
|
IP
|
$21.00
|
|
| Hospital Charge Code |
2893264
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$14.70 |
| Max. Negotiated Rate |
$21.00 |
| Rate for Payer: Aetna Commercial |
$19.95
|
| Rate for Payer: Aetna Medicare |
$18.90
|
| Rate for Payer: BCBS MT CHIP |
$18.90
|
| Rate for Payer: BCBS MT Closed Plan Network |
$19.95
|
| Rate for Payer: BCBS MT HealthLink |
$18.90
|
| Rate for Payer: BCBS MT Medicare |
$18.90
|
| Rate for Payer: BCBS MT POS |
$19.95
|
| Rate for Payer: BCBS MT Traditional |
$21.00
|
| Rate for Payer: Cash Price |
$18.90
|
| Rate for Payer: Cigna Commercial |
$19.95
|
| Rate for Payer: Cigna Medicare |
$18.90
|
| Rate for Payer: Medicaid All Medicaid |
$19.32
|
| Rate for Payer: Medicare All Medicare |
$14.70
|
| Rate for Payer: Monida Allegiance |
$19.95
|
| Rate for Payer: Monida First Choice Health |
$20.37
|
| Rate for Payer: Monida Montana Health Co-op |
$19.95
|
| Rate for Payer: Monida PacificSource |
$19.95
|
|
|
CLAVICAL SPLINT XL
|
Facility
|
OP
|
$21.00
|
|
| Hospital Charge Code |
2893267
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$14.70 |
| Max. Negotiated Rate |
$21.00 |
| Rate for Payer: Aetna Commercial |
$19.95
|
| Rate for Payer: Aetna Medicare |
$18.90
|
| Rate for Payer: BCBS MT CHIP |
$18.90
|
| Rate for Payer: BCBS MT Closed Plan Network |
$19.95
|
| Rate for Payer: BCBS MT HealthLink |
$18.90
|
| Rate for Payer: BCBS MT Medicare |
$18.90
|
| Rate for Payer: BCBS MT POS |
$19.95
|
| Rate for Payer: BCBS MT Traditional |
$21.00
|
| Rate for Payer: Cash Price |
$18.90
|
| Rate for Payer: Cigna Commercial |
$19.95
|
| Rate for Payer: Cigna Medicare |
$18.90
|
| Rate for Payer: Medicaid All Medicaid |
$19.32
|
| Rate for Payer: Medicare All Medicare |
$14.70
|
| Rate for Payer: Monida Allegiance |
$19.95
|
| Rate for Payer: Monida First Choice Health |
$20.37
|
| Rate for Payer: Monida Montana Health Co-op |
$19.95
|
| Rate for Payer: Monida PacificSource |
$19.95
|
|
|
CLAVICAL SPLINT XL
|
Facility
|
IP
|
$21.00
|
|
| Hospital Charge Code |
2893267
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$14.70 |
| Max. Negotiated Rate |
$21.00 |
| Rate for Payer: Aetna Commercial |
$19.95
|
| Rate for Payer: Aetna Medicare |
$18.90
|
| Rate for Payer: BCBS MT CHIP |
$18.90
|
| Rate for Payer: BCBS MT Closed Plan Network |
$19.95
|
| Rate for Payer: BCBS MT HealthLink |
$18.90
|
| Rate for Payer: BCBS MT Medicare |
$18.90
|
| Rate for Payer: BCBS MT POS |
$19.95
|
| Rate for Payer: BCBS MT Traditional |
$21.00
|
| Rate for Payer: Cash Price |
$18.90
|
| Rate for Payer: Cigna Commercial |
$19.95
|
| Rate for Payer: Cigna Medicare |
$18.90
|
| Rate for Payer: Medicaid All Medicaid |
$19.32
|
| Rate for Payer: Medicare All Medicare |
$14.70
|
| Rate for Payer: Monida Allegiance |
$19.95
|
| Rate for Payer: Monida First Choice Health |
$20.37
|
| Rate for Payer: Monida Montana Health Co-op |
$19.95
|
| Rate for Payer: Monida PacificSource |
$19.95
|
|
|
CLAVICL SPLINT UNIVERSAL
|
Facility
|
OP
|
$40.00
|
|
| Hospital Charge Code |
2893268
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$28.00 |
| Max. Negotiated Rate |
$40.00 |
| Rate for Payer: Aetna Commercial |
$38.00
|
| Rate for Payer: Aetna Medicare |
$36.00
|
| Rate for Payer: BCBS MT CHIP |
$36.00
|
| Rate for Payer: BCBS MT Closed Plan Network |
$38.00
|
| Rate for Payer: BCBS MT HealthLink |
$36.00
|
| Rate for Payer: BCBS MT Medicare |
$36.00
|
| Rate for Payer: BCBS MT POS |
$38.00
|
| Rate for Payer: BCBS MT Traditional |
$40.00
|
| Rate for Payer: Cash Price |
$36.00
|
| Rate for Payer: Cigna Commercial |
$38.00
|
| Rate for Payer: Cigna Medicare |
$36.00
|
| Rate for Payer: Medicaid All Medicaid |
$36.80
|
| Rate for Payer: Medicare All Medicare |
$28.00
|
| Rate for Payer: Monida Allegiance |
$38.00
|
| Rate for Payer: Monida First Choice Health |
$38.80
|
| Rate for Payer: Monida Montana Health Co-op |
$38.00
|
| Rate for Payer: Monida PacificSource |
$38.00
|
|
|
CLAVICL SPLINT UNIVERSAL
|
Facility
|
IP
|
$40.00
|
|
| Hospital Charge Code |
2893268
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$28.00 |
| Max. Negotiated Rate |
$40.00 |
| Rate for Payer: Aetna Commercial |
$38.00
|
| Rate for Payer: Aetna Medicare |
$36.00
|
| Rate for Payer: BCBS MT CHIP |
$36.00
|
| Rate for Payer: BCBS MT Closed Plan Network |
$38.00
|
| Rate for Payer: BCBS MT HealthLink |
$36.00
|
| Rate for Payer: BCBS MT Medicare |
$36.00
|
| Rate for Payer: BCBS MT POS |
$38.00
|
| Rate for Payer: BCBS MT Traditional |
$40.00
|
| Rate for Payer: Cash Price |
$36.00
|
| Rate for Payer: Cigna Commercial |
$38.00
|
| Rate for Payer: Cigna Medicare |
$36.00
|
| Rate for Payer: Medicaid All Medicaid |
$36.80
|
| Rate for Payer: Medicare All Medicare |
$28.00
|
| Rate for Payer: Monida Allegiance |
$38.00
|
| Rate for Payer: Monida First Choice Health |
$38.80
|
| Rate for Payer: Monida Montana Health Co-op |
$38.00
|
| Rate for Payer: Monida PacificSource |
$38.00
|
|
|
CLEANSING FOAM
|
Facility
|
IP
|
$25.00
|
|
| Hospital Charge Code |
2830251
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$17.50 |
| Max. Negotiated Rate |
$25.00 |
| Rate for Payer: Aetna Commercial |
$23.75
|
| Rate for Payer: Aetna Medicare |
$22.50
|
| Rate for Payer: BCBS MT CHIP |
$22.50
|
| Rate for Payer: BCBS MT Closed Plan Network |
$23.75
|
| Rate for Payer: BCBS MT HealthLink |
$22.50
|
| Rate for Payer: BCBS MT Medicare |
$22.50
|
| Rate for Payer: BCBS MT POS |
$23.75
|
| Rate for Payer: BCBS MT Traditional |
$25.00
|
| Rate for Payer: Cash Price |
$22.50
|
| Rate for Payer: Cigna Commercial |
$23.75
|
| Rate for Payer: Cigna Medicare |
$22.50
|
| Rate for Payer: Medicaid All Medicaid |
$23.00
|
| Rate for Payer: Medicare All Medicare |
$17.50
|
| Rate for Payer: Monida Allegiance |
$23.75
|
| Rate for Payer: Monida First Choice Health |
$24.25
|
| Rate for Payer: Monida Montana Health Co-op |
$23.75
|
| Rate for Payer: Monida PacificSource |
$23.75
|
|
|
CLEANSING FOAM
|
Facility
|
OP
|
$25.00
|
|
| Hospital Charge Code |
2830251
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$17.50 |
| Max. Negotiated Rate |
$25.00 |
| Rate for Payer: Aetna Commercial |
$23.75
|
| Rate for Payer: Aetna Medicare |
$22.50
|
| Rate for Payer: BCBS MT CHIP |
$22.50
|
| Rate for Payer: BCBS MT Closed Plan Network |
$23.75
|
| Rate for Payer: BCBS MT HealthLink |
$22.50
|
| Rate for Payer: BCBS MT Medicare |
$22.50
|
| Rate for Payer: BCBS MT POS |
$23.75
|
| Rate for Payer: BCBS MT Traditional |
$25.00
|
| Rate for Payer: Cash Price |
$22.50
|
| Rate for Payer: Cigna Commercial |
$23.75
|
| Rate for Payer: Cigna Medicare |
$22.50
|
| Rate for Payer: Medicaid All Medicaid |
$23.00
|
| Rate for Payer: Medicare All Medicare |
$17.50
|
| Rate for Payer: Monida Allegiance |
$23.75
|
| Rate for Payer: Monida First Choice Health |
$24.25
|
| Rate for Payer: Monida Montana Health Co-op |
$23.75
|
| Rate for Payer: Monida PacificSource |
$23.75
|
|
|
CLIA CERTIFICATE
|
Facility
|
OP
|
$248.00
|
|
| Hospital Charge Code |
90197135
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$173.60 |
| Max. Negotiated Rate |
$248.00 |
| Rate for Payer: Aetna Commercial |
$235.60
|
| Rate for Payer: Aetna Medicare |
$223.20
|
| Rate for Payer: BCBS MT CHIP |
$223.20
|
| Rate for Payer: BCBS MT Closed Plan Network |
$235.60
|
| Rate for Payer: BCBS MT HealthLink |
$223.20
|
| Rate for Payer: BCBS MT Medicare |
$223.20
|
| Rate for Payer: BCBS MT POS |
$235.60
|
| Rate for Payer: BCBS MT Traditional |
$248.00
|
| Rate for Payer: Cash Price |
$223.20
|
| Rate for Payer: Cigna Commercial |
$235.60
|
| Rate for Payer: Cigna Medicare |
$223.20
|
| Rate for Payer: Medicaid All Medicaid |
$228.16
|
| Rate for Payer: Medicare All Medicare |
$173.60
|
| Rate for Payer: Monida Allegiance |
$235.60
|
| Rate for Payer: Monida First Choice Health |
$240.56
|
| Rate for Payer: Monida Montana Health Co-op |
$235.60
|
| Rate for Payer: Monida PacificSource |
$235.60
|
|
|
CLIA CERTIFICATE
|
Facility
|
IP
|
$248.00
|
|
| Hospital Charge Code |
90197135
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$173.60 |
| Max. Negotiated Rate |
$248.00 |
| Rate for Payer: Aetna Commercial |
$235.60
|
| Rate for Payer: Aetna Medicare |
$223.20
|
| Rate for Payer: BCBS MT CHIP |
$223.20
|
| Rate for Payer: BCBS MT Closed Plan Network |
$235.60
|
| Rate for Payer: BCBS MT HealthLink |
$223.20
|
| Rate for Payer: BCBS MT Medicare |
$223.20
|
| Rate for Payer: BCBS MT POS |
$235.60
|
| Rate for Payer: BCBS MT Traditional |
$248.00
|
| Rate for Payer: Cash Price |
$223.20
|
| Rate for Payer: Cigna Commercial |
$235.60
|
| Rate for Payer: Cigna Medicare |
$223.20
|
| Rate for Payer: Medicaid All Medicaid |
$228.16
|
| Rate for Payer: Medicare All Medicare |
$173.60
|
| Rate for Payer: Monida Allegiance |
$235.60
|
| Rate for Payer: Monida First Choice Health |
$240.56
|
| Rate for Payer: Monida Montana Health Co-op |
$235.60
|
| Rate for Payer: Monida PacificSource |
$235.60
|
|
|
CLIN ACETAMINOPHEN ELIX [160 MG/5 ML]
|
Facility
|
IP
|
$5.00
|
|
| Hospital Charge Code |
8007000
|
|
Hospital Revenue Code
|
521
|
| 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
|
|
|
CLIN ACETAMINOPHEN ELIX [160 MG/5 ML]
|
Facility
|
OP
|
$5.00
|
|
| Hospital Charge Code |
8007000
|
|
Hospital Revenue Code
|
521
|
| 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
|
|
|
CLIN AMLODIPINE [5MG] TABLET
|
Facility
|
OP
|
$5.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
8007001
|
|
Hospital Revenue Code
|
521
|
| 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
|
|
|
CLIN AMLODIPINE [5MG] TABLET
|
Facility
|
IP
|
$5.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
8007001
|
|
Hospital Revenue Code
|
521
|
| 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
|
|
|
CLIN ASPIRIN CHEW TAB [81 MG]
|
Facility
|
IP
|
$5.00
|
|
|
Service Code
|
CPT 4086F
|
| Hospital Charge Code |
8007002
|
|
Hospital Revenue Code
|
521
|
| 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
|
|
|
CLIN ASPIRIN CHEW TAB [81 MG]
|
Facility
|
OP
|
$5.00
|
|
|
Service Code
|
CPT 4086F
|
| Hospital Charge Code |
8007002
|
|
Hospital Revenue Code
|
521
|
| 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
|
|
