|
CRITICAL CARE (EA 1/2 HR)
|
Facility
|
OP
|
$628.00
|
|
|
Service Code
|
CPT 99292
|
| Hospital Charge Code |
1010108
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$439.60 |
| Max. Negotiated Rate |
$628.00 |
| Rate for Payer: Aetna Commercial |
$596.60
|
| Rate for Payer: Aetna Medicare |
$565.20
|
| Rate for Payer: BCBS MT CHIP |
$565.20
|
| Rate for Payer: BCBS MT Closed Plan Network |
$596.60
|
| Rate for Payer: BCBS MT HealthLink |
$565.20
|
| Rate for Payer: BCBS MT Medicare |
$565.20
|
| Rate for Payer: BCBS MT POS |
$596.60
|
| Rate for Payer: BCBS MT Traditional |
$628.00
|
| Rate for Payer: Cash Price |
$565.20
|
| Rate for Payer: Cigna Commercial |
$596.60
|
| Rate for Payer: Cigna Medicare |
$565.20
|
| Rate for Payer: Medicaid All Medicaid |
$577.76
|
| Rate for Payer: Medicare All Medicare |
$439.60
|
| Rate for Payer: Monida Allegiance |
$596.60
|
| Rate for Payer: Monida First Choice Health |
$609.16
|
| Rate for Payer: Monida Montana Health Co-op |
$596.60
|
| Rate for Payer: Monida PacificSource |
$596.60
|
|
|
CROTALIDAE IMMUNE FAB2 VIAL
|
Facility
|
IP
|
$2,218.00
|
|
|
Service Code
|
HCPCS J0841
|
| Hospital Charge Code |
3000537
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1,552.60 |
| Max. Negotiated Rate |
$2,218.00 |
| Rate for Payer: Aetna Commercial |
$2,107.10
|
| Rate for Payer: Aetna Medicare |
$1,996.20
|
| Rate for Payer: BCBS MT CHIP |
$1,996.20
|
| Rate for Payer: BCBS MT Closed Plan Network |
$2,107.10
|
| Rate for Payer: BCBS MT HealthLink |
$1,996.20
|
| Rate for Payer: BCBS MT Medicare |
$1,996.20
|
| Rate for Payer: BCBS MT POS |
$2,107.10
|
| Rate for Payer: BCBS MT Traditional |
$2,218.00
|
| Rate for Payer: Cash Price |
$1,996.20
|
| Rate for Payer: Cigna Commercial |
$2,107.10
|
| Rate for Payer: Cigna Medicare |
$1,996.20
|
| Rate for Payer: Medicaid All Medicaid |
$2,040.56
|
| Rate for Payer: Medicare All Medicare |
$1,552.60
|
| Rate for Payer: Monida Allegiance |
$2,107.10
|
| Rate for Payer: Monida First Choice Health |
$2,151.46
|
| Rate for Payer: Monida Montana Health Co-op |
$2,107.10
|
| Rate for Payer: Monida PacificSource |
$2,107.10
|
|
|
CROTALIDAE IMMUNE FAB2 VIAL
|
Facility
|
OP
|
$2,218.00
|
|
|
Service Code
|
HCPCS J0841
|
| Hospital Charge Code |
3000537
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1,552.60 |
| Max. Negotiated Rate |
$2,218.00 |
| Rate for Payer: Aetna Commercial |
$2,107.10
|
| Rate for Payer: Aetna Medicare |
$1,996.20
|
| Rate for Payer: BCBS MT CHIP |
$1,996.20
|
| Rate for Payer: BCBS MT Closed Plan Network |
$2,107.10
|
| Rate for Payer: BCBS MT HealthLink |
$1,996.20
|
| Rate for Payer: BCBS MT Medicare |
$1,996.20
|
| Rate for Payer: BCBS MT POS |
$2,107.10
|
| Rate for Payer: BCBS MT Traditional |
$2,218.00
|
| Rate for Payer: Cash Price |
$1,996.20
|
| Rate for Payer: Cigna Commercial |
$2,107.10
|
| Rate for Payer: Cigna Medicare |
$1,996.20
|
| Rate for Payer: Medicaid All Medicaid |
$2,040.56
|
| Rate for Payer: Medicare All Medicare |
$1,552.60
|
| Rate for Payer: Monida Allegiance |
$2,107.10
|
| Rate for Payer: Monida First Choice Health |
$2,151.46
|
| Rate for Payer: Monida Montana Health Co-op |
$2,107.10
|
| Rate for Payer: Monida PacificSource |
$2,107.10
|
|
|
CRP HIGH SENSITIVITY (120766)
|
Facility
|
IP
|
$69.00
|
|
|
Service Code
|
CPT 86141
|
| Hospital Charge Code |
4086141
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$48.30 |
| Max. Negotiated Rate |
$69.00 |
| Rate for Payer: Aetna Commercial |
$65.55
|
| Rate for Payer: Aetna Medicare |
$62.10
|
| Rate for Payer: BCBS MT CHIP |
$62.10
|
| Rate for Payer: BCBS MT Closed Plan Network |
$65.55
|
| Rate for Payer: BCBS MT HealthLink |
$62.10
|
| Rate for Payer: BCBS MT Medicare |
$62.10
|
| Rate for Payer: BCBS MT POS |
$65.55
|
| Rate for Payer: BCBS MT Traditional |
$69.00
|
| Rate for Payer: Cash Price |
$62.10
|
| Rate for Payer: Cigna Commercial |
$65.55
|
| Rate for Payer: Cigna Medicare |
$62.10
|
| Rate for Payer: Medicaid All Medicaid |
$63.48
|
| Rate for Payer: Medicare All Medicare |
$48.30
|
| Rate for Payer: Monida Allegiance |
$65.55
|
| Rate for Payer: Monida First Choice Health |
$66.93
|
| Rate for Payer: Monida Montana Health Co-op |
$65.55
|
| Rate for Payer: Monida PacificSource |
$65.55
|
|
|
CRP HIGH SENSITIVITY (120766)
|
Facility
|
OP
|
$69.00
|
|
|
Service Code
|
CPT 86141
|
| Hospital Charge Code |
4086141
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$48.30 |
| Max. Negotiated Rate |
$69.00 |
| Rate for Payer: Aetna Commercial |
$65.55
|
| Rate for Payer: Aetna Medicare |
$62.10
|
| Rate for Payer: BCBS MT CHIP |
$62.10
|
| Rate for Payer: BCBS MT Closed Plan Network |
$65.55
|
| Rate for Payer: BCBS MT HealthLink |
$62.10
|
| Rate for Payer: BCBS MT Medicare |
$62.10
|
| Rate for Payer: BCBS MT POS |
$65.55
|
| Rate for Payer: BCBS MT Traditional |
$69.00
|
| Rate for Payer: Cash Price |
$62.10
|
| Rate for Payer: Cigna Commercial |
$65.55
|
| Rate for Payer: Cigna Medicare |
$62.10
|
| Rate for Payer: Medicaid All Medicaid |
$63.48
|
| Rate for Payer: Medicare All Medicare |
$48.30
|
| Rate for Payer: Monida Allegiance |
$65.55
|
| Rate for Payer: Monida First Choice Health |
$66.93
|
| Rate for Payer: Monida Montana Health Co-op |
$65.55
|
| Rate for Payer: Monida PacificSource |
$65.55
|
|
|
CRUTCH ADULT 5'1-5'9
|
Facility
|
OP
|
$57.00
|
|
|
Service Code
|
HCPCS E0116
|
| Hospital Charge Code |
2893283
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$39.90 |
| Max. Negotiated Rate |
$57.00 |
| Rate for Payer: Aetna Commercial |
$54.15
|
| Rate for Payer: Aetna Medicare |
$51.30
|
| Rate for Payer: BCBS MT CHIP |
$51.30
|
| Rate for Payer: BCBS MT Closed Plan Network |
$54.15
|
| Rate for Payer: BCBS MT HealthLink |
$51.30
|
| Rate for Payer: BCBS MT Medicare |
$51.30
|
| Rate for Payer: BCBS MT POS |
$54.15
|
| Rate for Payer: BCBS MT Traditional |
$57.00
|
| Rate for Payer: Cash Price |
$51.30
|
| Rate for Payer: Cigna Commercial |
$54.15
|
| Rate for Payer: Cigna Medicare |
$51.30
|
| Rate for Payer: Medicaid All Medicaid |
$52.44
|
| Rate for Payer: Medicare All Medicare |
$39.90
|
| Rate for Payer: Monida Allegiance |
$54.15
|
| Rate for Payer: Monida First Choice Health |
$55.29
|
| Rate for Payer: Monida Montana Health Co-op |
$54.15
|
| Rate for Payer: Monida PacificSource |
$54.15
|
|
|
CRUTCH ADULT 5'1-5'9
|
Facility
|
IP
|
$57.00
|
|
|
Service Code
|
HCPCS E0116
|
| Hospital Charge Code |
2893283
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$39.90 |
| Max. Negotiated Rate |
$57.00 |
| Rate for Payer: Aetna Commercial |
$54.15
|
| Rate for Payer: Aetna Medicare |
$51.30
|
| Rate for Payer: BCBS MT CHIP |
$51.30
|
| Rate for Payer: BCBS MT Closed Plan Network |
$54.15
|
| Rate for Payer: BCBS MT HealthLink |
$51.30
|
| Rate for Payer: BCBS MT Medicare |
$51.30
|
| Rate for Payer: BCBS MT POS |
$54.15
|
| Rate for Payer: BCBS MT Traditional |
$57.00
|
| Rate for Payer: Cash Price |
$51.30
|
| Rate for Payer: Cigna Commercial |
$54.15
|
| Rate for Payer: Cigna Medicare |
$51.30
|
| Rate for Payer: Medicaid All Medicaid |
$52.44
|
| Rate for Payer: Medicare All Medicare |
$39.90
|
| Rate for Payer: Monida Allegiance |
$54.15
|
| Rate for Payer: Monida First Choice Health |
$55.29
|
| Rate for Payer: Monida Montana Health Co-op |
$54.15
|
| Rate for Payer: Monida PacificSource |
$54.15
|
|
|
CRUTCH ADULT TALL 5'10'
|
Facility
|
OP
|
$95.00
|
|
|
Service Code
|
HCPCS E0116
|
| Hospital Charge Code |
2893282
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$66.50 |
| Max. Negotiated Rate |
$95.00 |
| Rate for Payer: Aetna Commercial |
$90.25
|
| Rate for Payer: Aetna Medicare |
$85.50
|
| Rate for Payer: BCBS MT CHIP |
$85.50
|
| Rate for Payer: BCBS MT Closed Plan Network |
$90.25
|
| Rate for Payer: BCBS MT HealthLink |
$85.50
|
| Rate for Payer: BCBS MT Medicare |
$85.50
|
| Rate for Payer: BCBS MT POS |
$90.25
|
| Rate for Payer: BCBS MT Traditional |
$95.00
|
| Rate for Payer: Cash Price |
$85.50
|
| Rate for Payer: Cigna Commercial |
$90.25
|
| Rate for Payer: Cigna Medicare |
$85.50
|
| Rate for Payer: Medicaid All Medicaid |
$87.40
|
| Rate for Payer: Medicare All Medicare |
$66.50
|
| Rate for Payer: Monida Allegiance |
$90.25
|
| Rate for Payer: Monida First Choice Health |
$92.15
|
| Rate for Payer: Monida Montana Health Co-op |
$90.25
|
| Rate for Payer: Monida PacificSource |
$90.25
|
|
|
CRUTCH ADULT TALL 5'10'
|
Facility
|
IP
|
$95.00
|
|
|
Service Code
|
HCPCS E0116
|
| Hospital Charge Code |
2893282
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$66.50 |
| Max. Negotiated Rate |
$95.00 |
| Rate for Payer: Aetna Commercial |
$90.25
|
| Rate for Payer: Aetna Medicare |
$85.50
|
| Rate for Payer: BCBS MT CHIP |
$85.50
|
| Rate for Payer: BCBS MT Closed Plan Network |
$90.25
|
| Rate for Payer: BCBS MT HealthLink |
$85.50
|
| Rate for Payer: BCBS MT Medicare |
$85.50
|
| Rate for Payer: BCBS MT POS |
$90.25
|
| Rate for Payer: BCBS MT Traditional |
$95.00
|
| Rate for Payer: Cash Price |
$85.50
|
| Rate for Payer: Cigna Commercial |
$90.25
|
| Rate for Payer: Cigna Medicare |
$85.50
|
| Rate for Payer: Medicaid All Medicaid |
$87.40
|
| Rate for Payer: Medicare All Medicare |
$66.50
|
| Rate for Payer: Monida Allegiance |
$90.25
|
| Rate for Payer: Monida First Choice Health |
$92.15
|
| Rate for Payer: Monida Montana Health Co-op |
$90.25
|
| Rate for Payer: Monida PacificSource |
$90.25
|
|
|
CRUTCH DRESSED CHILD
|
Facility
|
IP
|
$57.00
|
|
|
Service Code
|
HCPCS E0116
|
| Hospital Charge Code |
2893284
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$39.90 |
| Max. Negotiated Rate |
$57.00 |
| Rate for Payer: Aetna Commercial |
$54.15
|
| Rate for Payer: Aetna Medicare |
$51.30
|
| Rate for Payer: BCBS MT CHIP |
$51.30
|
| Rate for Payer: BCBS MT Closed Plan Network |
$54.15
|
| Rate for Payer: BCBS MT HealthLink |
$51.30
|
| Rate for Payer: BCBS MT Medicare |
$51.30
|
| Rate for Payer: BCBS MT POS |
$54.15
|
| Rate for Payer: BCBS MT Traditional |
$57.00
|
| Rate for Payer: Cash Price |
$51.30
|
| Rate for Payer: Cigna Commercial |
$54.15
|
| Rate for Payer: Cigna Medicare |
$51.30
|
| Rate for Payer: Medicaid All Medicaid |
$52.44
|
| Rate for Payer: Medicare All Medicare |
$39.90
|
| Rate for Payer: Monida Allegiance |
$54.15
|
| Rate for Payer: Monida First Choice Health |
$55.29
|
| Rate for Payer: Monida Montana Health Co-op |
$54.15
|
| Rate for Payer: Monida PacificSource |
$54.15
|
|
|
CRUTCH DRESSED CHILD
|
Facility
|
OP
|
$57.00
|
|
|
Service Code
|
HCPCS E0116
|
| Hospital Charge Code |
2893284
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$39.90 |
| Max. Negotiated Rate |
$57.00 |
| Rate for Payer: Aetna Commercial |
$54.15
|
| Rate for Payer: Aetna Medicare |
$51.30
|
| Rate for Payer: BCBS MT CHIP |
$51.30
|
| Rate for Payer: BCBS MT Closed Plan Network |
$54.15
|
| Rate for Payer: BCBS MT HealthLink |
$51.30
|
| Rate for Payer: BCBS MT Medicare |
$51.30
|
| Rate for Payer: BCBS MT POS |
$54.15
|
| Rate for Payer: BCBS MT Traditional |
$57.00
|
| Rate for Payer: Cash Price |
$51.30
|
| Rate for Payer: Cigna Commercial |
$54.15
|
| Rate for Payer: Cigna Medicare |
$51.30
|
| Rate for Payer: Medicaid All Medicaid |
$52.44
|
| Rate for Payer: Medicare All Medicare |
$39.90
|
| Rate for Payer: Monida Allegiance |
$54.15
|
| Rate for Payer: Monida First Choice Health |
$55.29
|
| Rate for Payer: Monida Montana Health Co-op |
$54.15
|
| Rate for Payer: Monida PacificSource |
$54.15
|
|
|
CRUTCH YOUTH 4'6 - 5'2
|
Facility
|
OP
|
$66.00
|
|
|
Service Code
|
HCPCS E0116
|
| Hospital Charge Code |
2870012
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$46.20 |
| Max. Negotiated Rate |
$66.00 |
| Rate for Payer: Aetna Commercial |
$62.70
|
| Rate for Payer: Aetna Medicare |
$59.40
|
| Rate for Payer: BCBS MT CHIP |
$59.40
|
| Rate for Payer: BCBS MT Closed Plan Network |
$62.70
|
| Rate for Payer: BCBS MT HealthLink |
$59.40
|
| Rate for Payer: BCBS MT Medicare |
$59.40
|
| Rate for Payer: BCBS MT POS |
$62.70
|
| Rate for Payer: BCBS MT Traditional |
$66.00
|
| Rate for Payer: Cash Price |
$59.40
|
| Rate for Payer: Cigna Commercial |
$62.70
|
| Rate for Payer: Cigna Medicare |
$59.40
|
| Rate for Payer: Medicaid All Medicaid |
$60.72
|
| Rate for Payer: Medicare All Medicare |
$46.20
|
| Rate for Payer: Monida Allegiance |
$62.70
|
| Rate for Payer: Monida First Choice Health |
$64.02
|
| Rate for Payer: Monida Montana Health Co-op |
$62.70
|
| Rate for Payer: Monida PacificSource |
$62.70
|
|
|
CRUTCH YOUTH 4'6 - 5'2
|
Facility
|
IP
|
$66.00
|
|
|
Service Code
|
HCPCS E0116
|
| Hospital Charge Code |
2870012
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$46.20 |
| Max. Negotiated Rate |
$66.00 |
| Rate for Payer: Aetna Commercial |
$62.70
|
| Rate for Payer: Aetna Medicare |
$59.40
|
| Rate for Payer: BCBS MT CHIP |
$59.40
|
| Rate for Payer: BCBS MT Closed Plan Network |
$62.70
|
| Rate for Payer: BCBS MT HealthLink |
$59.40
|
| Rate for Payer: BCBS MT Medicare |
$59.40
|
| Rate for Payer: BCBS MT POS |
$62.70
|
| Rate for Payer: BCBS MT Traditional |
$66.00
|
| Rate for Payer: Cash Price |
$59.40
|
| Rate for Payer: Cigna Commercial |
$62.70
|
| Rate for Payer: Cigna Medicare |
$59.40
|
| Rate for Payer: Medicaid All Medicaid |
$60.72
|
| Rate for Payer: Medicare All Medicare |
$46.20
|
| Rate for Payer: Monida Allegiance |
$62.70
|
| Rate for Payer: Monida First Choice Health |
$64.02
|
| Rate for Payer: Monida Montana Health Co-op |
$62.70
|
| Rate for Payer: Monida PacificSource |
$62.70
|
|
|
CRYOTHERAPY ACNE
|
Facility
|
OP
|
$196.00
|
|
|
Service Code
|
CPT 17340
|
| Hospital Charge Code |
8017340
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$137.20 |
| Max. Negotiated Rate |
$196.00 |
| Rate for Payer: Aetna Commercial |
$186.20
|
| Rate for Payer: Aetna Medicare |
$176.40
|
| Rate for Payer: BCBS MT CHIP |
$176.40
|
| Rate for Payer: BCBS MT Closed Plan Network |
$186.20
|
| Rate for Payer: BCBS MT HealthLink |
$176.40
|
| Rate for Payer: BCBS MT Medicare |
$176.40
|
| Rate for Payer: BCBS MT POS |
$186.20
|
| Rate for Payer: BCBS MT Traditional |
$196.00
|
| Rate for Payer: Cash Price |
$176.40
|
| Rate for Payer: Cigna Commercial |
$186.20
|
| Rate for Payer: Cigna Medicare |
$176.40
|
| Rate for Payer: Medicaid All Medicaid |
$180.32
|
| Rate for Payer: Medicare All Medicare |
$137.20
|
| Rate for Payer: Monida Allegiance |
$186.20
|
| Rate for Payer: Monida First Choice Health |
$190.12
|
| Rate for Payer: Monida Montana Health Co-op |
$186.20
|
| Rate for Payer: Monida PacificSource |
$186.20
|
|
|
CRYOTHERAPY ACNE
|
Facility
|
IP
|
$196.00
|
|
|
Service Code
|
CPT 17340
|
| Hospital Charge Code |
8017340
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$137.20 |
| Max. Negotiated Rate |
$196.00 |
| Rate for Payer: Aetna Commercial |
$186.20
|
| Rate for Payer: Aetna Medicare |
$176.40
|
| Rate for Payer: BCBS MT CHIP |
$176.40
|
| Rate for Payer: BCBS MT Closed Plan Network |
$186.20
|
| Rate for Payer: BCBS MT HealthLink |
$176.40
|
| Rate for Payer: BCBS MT Medicare |
$176.40
|
| Rate for Payer: BCBS MT POS |
$186.20
|
| Rate for Payer: BCBS MT Traditional |
$196.00
|
| Rate for Payer: Cash Price |
$176.40
|
| Rate for Payer: Cigna Commercial |
$186.20
|
| Rate for Payer: Cigna Medicare |
$176.40
|
| Rate for Payer: Medicaid All Medicaid |
$180.32
|
| Rate for Payer: Medicare All Medicare |
$137.20
|
| Rate for Payer: Monida Allegiance |
$186.20
|
| Rate for Payer: Monida First Choice Health |
$190.12
|
| Rate for Payer: Monida Montana Health Co-op |
$186.20
|
| Rate for Payer: Monida PacificSource |
$186.20
|
|
|
CRYPTOSPORIDUM, EIA (183020)
|
Facility
|
OP
|
$206.00
|
|
|
Service Code
|
CPT 87328
|
| Hospital Charge Code |
4087328
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$144.20 |
| Max. Negotiated Rate |
$206.00 |
| Rate for Payer: Aetna Commercial |
$195.70
|
| Rate for Payer: Aetna Medicare |
$185.40
|
| Rate for Payer: BCBS MT CHIP |
$185.40
|
| Rate for Payer: BCBS MT Closed Plan Network |
$195.70
|
| Rate for Payer: BCBS MT HealthLink |
$185.40
|
| Rate for Payer: BCBS MT Medicare |
$185.40
|
| Rate for Payer: BCBS MT POS |
$195.70
|
| Rate for Payer: BCBS MT Traditional |
$206.00
|
| Rate for Payer: Cash Price |
$185.40
|
| Rate for Payer: Cigna Commercial |
$195.70
|
| Rate for Payer: Cigna Medicare |
$185.40
|
| Rate for Payer: Medicaid All Medicaid |
$189.52
|
| Rate for Payer: Medicare All Medicare |
$144.20
|
| Rate for Payer: Monida Allegiance |
$195.70
|
| Rate for Payer: Monida First Choice Health |
$199.82
|
| Rate for Payer: Monida Montana Health Co-op |
$195.70
|
| Rate for Payer: Monida PacificSource |
$195.70
|
|
|
CRYPTOSPORIDUM, EIA (183020)
|
Facility
|
IP
|
$206.00
|
|
|
Service Code
|
CPT 87328
|
| Hospital Charge Code |
4087328
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$144.20 |
| Max. Negotiated Rate |
$206.00 |
| Rate for Payer: Aetna Commercial |
$195.70
|
| Rate for Payer: Aetna Medicare |
$185.40
|
| Rate for Payer: BCBS MT CHIP |
$185.40
|
| Rate for Payer: BCBS MT Closed Plan Network |
$195.70
|
| Rate for Payer: BCBS MT HealthLink |
$185.40
|
| Rate for Payer: BCBS MT Medicare |
$185.40
|
| Rate for Payer: BCBS MT POS |
$195.70
|
| Rate for Payer: BCBS MT Traditional |
$206.00
|
| Rate for Payer: Cash Price |
$185.40
|
| Rate for Payer: Cigna Commercial |
$195.70
|
| Rate for Payer: Cigna Medicare |
$185.40
|
| Rate for Payer: Medicaid All Medicaid |
$189.52
|
| Rate for Payer: Medicare All Medicare |
$144.20
|
| Rate for Payer: Monida Allegiance |
$195.70
|
| Rate for Payer: Monida First Choice Health |
$199.82
|
| Rate for Payer: Monida Montana Health Co-op |
$195.70
|
| Rate for Payer: Monida PacificSource |
$195.70
|
|
|
CRYSTAL BODY FLUID
|
Facility
|
OP
|
$95.00
|
|
|
Service Code
|
CPT 89060
|
| Hospital Charge Code |
4088060
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$66.50 |
| Max. Negotiated Rate |
$95.00 |
| Rate for Payer: Aetna Commercial |
$90.25
|
| Rate for Payer: Aetna Medicare |
$85.50
|
| Rate for Payer: BCBS MT CHIP |
$85.50
|
| Rate for Payer: BCBS MT Closed Plan Network |
$90.25
|
| Rate for Payer: BCBS MT HealthLink |
$85.50
|
| Rate for Payer: BCBS MT Medicare |
$85.50
|
| Rate for Payer: BCBS MT POS |
$90.25
|
| Rate for Payer: BCBS MT Traditional |
$95.00
|
| Rate for Payer: Cash Price |
$85.50
|
| Rate for Payer: Cigna Commercial |
$90.25
|
| Rate for Payer: Cigna Medicare |
$85.50
|
| Rate for Payer: Medicaid All Medicaid |
$87.40
|
| Rate for Payer: Medicare All Medicare |
$66.50
|
| Rate for Payer: Monida Allegiance |
$90.25
|
| Rate for Payer: Monida First Choice Health |
$92.15
|
| Rate for Payer: Monida Montana Health Co-op |
$90.25
|
| Rate for Payer: Monida PacificSource |
$90.25
|
|
|
CRYSTAL BODY FLUID
|
Facility
|
IP
|
$95.00
|
|
|
Service Code
|
CPT 89060
|
| Hospital Charge Code |
4088060
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$66.50 |
| Max. Negotiated Rate |
$95.00 |
| Rate for Payer: Aetna Commercial |
$90.25
|
| Rate for Payer: Aetna Medicare |
$85.50
|
| Rate for Payer: BCBS MT CHIP |
$85.50
|
| Rate for Payer: BCBS MT Closed Plan Network |
$90.25
|
| Rate for Payer: BCBS MT HealthLink |
$85.50
|
| Rate for Payer: BCBS MT Medicare |
$85.50
|
| Rate for Payer: BCBS MT POS |
$90.25
|
| Rate for Payer: BCBS MT Traditional |
$95.00
|
| Rate for Payer: Cash Price |
$85.50
|
| Rate for Payer: Cigna Commercial |
$90.25
|
| Rate for Payer: Cigna Medicare |
$85.50
|
| Rate for Payer: Medicaid All Medicaid |
$87.40
|
| Rate for Payer: Medicare All Medicare |
$66.50
|
| Rate for Payer: Monida Allegiance |
$90.25
|
| Rate for Payer: Monida First Choice Health |
$92.15
|
| Rate for Payer: Monida Montana Health Co-op |
$90.25
|
| Rate for Payer: Monida PacificSource |
$90.25
|
|
|
CT 3D RECONSTRUCTION
|
Facility
|
OP
|
$387.00
|
|
|
Service Code
|
CPT 76376
|
| Hospital Charge Code |
5200005
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$270.90 |
| Max. Negotiated Rate |
$387.00 |
| Rate for Payer: Aetna Commercial |
$367.65
|
| Rate for Payer: Aetna Medicare |
$348.30
|
| Rate for Payer: BCBS MT CHIP |
$348.30
|
| Rate for Payer: BCBS MT Closed Plan Network |
$367.65
|
| Rate for Payer: BCBS MT HealthLink |
$348.30
|
| Rate for Payer: BCBS MT Medicare |
$348.30
|
| Rate for Payer: BCBS MT POS |
$367.65
|
| Rate for Payer: BCBS MT Traditional |
$387.00
|
| Rate for Payer: Cash Price |
$348.30
|
| Rate for Payer: Cigna Commercial |
$367.65
|
| Rate for Payer: Cigna Medicare |
$348.30
|
| Rate for Payer: Medicaid All Medicaid |
$356.04
|
| Rate for Payer: Medicare All Medicare |
$270.90
|
| Rate for Payer: Monida Allegiance |
$367.65
|
| Rate for Payer: Monida First Choice Health |
$375.39
|
| Rate for Payer: Monida Montana Health Co-op |
$367.65
|
| Rate for Payer: Monida PacificSource |
$367.65
|
|
|
CT 3D RECONSTRUCTION
|
Facility
|
IP
|
$387.00
|
|
|
Service Code
|
CPT 76376
|
| Hospital Charge Code |
5200005
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$270.90 |
| Max. Negotiated Rate |
$387.00 |
| Rate for Payer: Aetna Commercial |
$367.65
|
| Rate for Payer: Aetna Medicare |
$348.30
|
| Rate for Payer: BCBS MT CHIP |
$348.30
|
| Rate for Payer: BCBS MT Closed Plan Network |
$367.65
|
| Rate for Payer: BCBS MT HealthLink |
$348.30
|
| Rate for Payer: BCBS MT Medicare |
$348.30
|
| Rate for Payer: BCBS MT POS |
$367.65
|
| Rate for Payer: BCBS MT Traditional |
$387.00
|
| Rate for Payer: Cash Price |
$348.30
|
| Rate for Payer: Cigna Commercial |
$367.65
|
| Rate for Payer: Cigna Medicare |
$348.30
|
| Rate for Payer: Medicaid All Medicaid |
$356.04
|
| Rate for Payer: Medicare All Medicare |
$270.90
|
| Rate for Payer: Monida Allegiance |
$367.65
|
| Rate for Payer: Monida First Choice Health |
$375.39
|
| Rate for Payer: Monida Montana Health Co-op |
$367.65
|
| Rate for Payer: Monida PacificSource |
$367.65
|
|
|
CTA ABDOMEN PELVIS W CONTRAST
|
Facility
|
IP
|
$2,975.00
|
|
|
Service Code
|
CPT 74174
|
| Hospital Charge Code |
5200053
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$2,082.50 |
| Max. Negotiated Rate |
$2,975.00 |
| Rate for Payer: Aetna Commercial |
$2,826.25
|
| Rate for Payer: Aetna Medicare |
$2,677.50
|
| Rate for Payer: BCBS MT CHIP |
$2,677.50
|
| Rate for Payer: BCBS MT Closed Plan Network |
$2,826.25
|
| Rate for Payer: BCBS MT HealthLink |
$2,677.50
|
| Rate for Payer: BCBS MT Medicare |
$2,677.50
|
| Rate for Payer: BCBS MT POS |
$2,826.25
|
| Rate for Payer: BCBS MT Traditional |
$2,975.00
|
| Rate for Payer: Cash Price |
$2,677.50
|
| Rate for Payer: Cigna Commercial |
$2,826.25
|
| Rate for Payer: Cigna Medicare |
$2,677.50
|
| Rate for Payer: Medicaid All Medicaid |
$2,737.00
|
| Rate for Payer: Medicare All Medicare |
$2,082.50
|
| Rate for Payer: Monida Allegiance |
$2,826.25
|
| Rate for Payer: Monida First Choice Health |
$2,885.75
|
| Rate for Payer: Monida Montana Health Co-op |
$2,826.25
|
| Rate for Payer: Monida PacificSource |
$2,826.25
|
|
|
CTA ABDOMEN PELVIS W CONTRAST
|
Facility
|
OP
|
$2,975.00
|
|
|
Service Code
|
CPT 74174
|
| Hospital Charge Code |
5200053
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$2,082.50 |
| Max. Negotiated Rate |
$2,975.00 |
| Rate for Payer: Aetna Commercial |
$2,826.25
|
| Rate for Payer: Aetna Medicare |
$2,677.50
|
| Rate for Payer: BCBS MT CHIP |
$2,677.50
|
| Rate for Payer: BCBS MT Closed Plan Network |
$2,826.25
|
| Rate for Payer: BCBS MT HealthLink |
$2,677.50
|
| Rate for Payer: BCBS MT Medicare |
$2,677.50
|
| Rate for Payer: BCBS MT POS |
$2,826.25
|
| Rate for Payer: BCBS MT Traditional |
$2,975.00
|
| Rate for Payer: Cash Price |
$2,677.50
|
| Rate for Payer: Cigna Commercial |
$2,826.25
|
| Rate for Payer: Cigna Medicare |
$2,677.50
|
| Rate for Payer: Medicaid All Medicaid |
$2,737.00
|
| Rate for Payer: Medicare All Medicare |
$2,082.50
|
| Rate for Payer: Monida Allegiance |
$2,826.25
|
| Rate for Payer: Monida First Choice Health |
$2,885.75
|
| Rate for Payer: Monida Montana Health Co-op |
$2,826.25
|
| Rate for Payer: Monida PacificSource |
$2,826.25
|
|
|
CTA ABDOMEN PELVIS W WO CONTRAST
|
Facility
|
IP
|
$2,975.00
|
|
|
Service Code
|
CPT 74174
|
| Hospital Charge Code |
5200250
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$2,082.50 |
| Max. Negotiated Rate |
$2,975.00 |
| Rate for Payer: Aetna Commercial |
$2,826.25
|
| Rate for Payer: Aetna Medicare |
$2,677.50
|
| Rate for Payer: BCBS MT CHIP |
$2,677.50
|
| Rate for Payer: BCBS MT Closed Plan Network |
$2,826.25
|
| Rate for Payer: BCBS MT HealthLink |
$2,677.50
|
| Rate for Payer: BCBS MT Medicare |
$2,677.50
|
| Rate for Payer: BCBS MT POS |
$2,826.25
|
| Rate for Payer: BCBS MT Traditional |
$2,975.00
|
| Rate for Payer: Cash Price |
$2,677.50
|
| Rate for Payer: Cigna Commercial |
$2,826.25
|
| Rate for Payer: Cigna Medicare |
$2,677.50
|
| Rate for Payer: Medicaid All Medicaid |
$2,737.00
|
| Rate for Payer: Medicare All Medicare |
$2,082.50
|
| Rate for Payer: Monida Allegiance |
$2,826.25
|
| Rate for Payer: Monida First Choice Health |
$2,885.75
|
| Rate for Payer: Monida Montana Health Co-op |
$2,826.25
|
| Rate for Payer: Monida PacificSource |
$2,826.25
|
|
|
CTA ABDOMEN PELVIS W WO CONTRAST
|
Facility
|
OP
|
$2,975.00
|
|
|
Service Code
|
CPT 74174
|
| Hospital Charge Code |
5200250
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$2,082.50 |
| Max. Negotiated Rate |
$2,975.00 |
| Rate for Payer: Aetna Commercial |
$2,826.25
|
| Rate for Payer: Aetna Medicare |
$2,677.50
|
| Rate for Payer: BCBS MT CHIP |
$2,677.50
|
| Rate for Payer: BCBS MT Closed Plan Network |
$2,826.25
|
| Rate for Payer: BCBS MT HealthLink |
$2,677.50
|
| Rate for Payer: BCBS MT Medicare |
$2,677.50
|
| Rate for Payer: BCBS MT POS |
$2,826.25
|
| Rate for Payer: BCBS MT Traditional |
$2,975.00
|
| Rate for Payer: Cash Price |
$2,677.50
|
| Rate for Payer: Cigna Commercial |
$2,826.25
|
| Rate for Payer: Cigna Medicare |
$2,677.50
|
| Rate for Payer: Medicaid All Medicaid |
$2,737.00
|
| Rate for Payer: Medicare All Medicare |
$2,082.50
|
| Rate for Payer: Monida Allegiance |
$2,826.25
|
| Rate for Payer: Monida First Choice Health |
$2,885.75
|
| Rate for Payer: Monida Montana Health Co-op |
$2,826.25
|
| Rate for Payer: Monida PacificSource |
$2,826.25
|
|
