|
ALDOLASE (002030)
|
Facility
|
OP
|
$14.00
|
|
|
Service Code
|
CPT 82085
|
| Hospital Charge Code |
4082085
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$9.80 |
| Max. Negotiated Rate |
$14.00 |
| Rate for Payer: Aetna Commercial |
$13.30
|
| Rate for Payer: Aetna Medicare |
$12.60
|
| Rate for Payer: BCBS MT CHIP |
$12.60
|
| Rate for Payer: BCBS MT Closed Plan Network |
$13.30
|
| Rate for Payer: BCBS MT HealthLink |
$12.60
|
| Rate for Payer: BCBS MT Medicare |
$12.60
|
| Rate for Payer: BCBS MT POS |
$13.30
|
| Rate for Payer: BCBS MT Traditional |
$14.00
|
| Rate for Payer: Cash Price |
$12.60
|
| Rate for Payer: Cigna Commercial |
$13.30
|
| Rate for Payer: Cigna Medicare |
$12.60
|
| Rate for Payer: Medicaid All Medicaid |
$12.88
|
| Rate for Payer: Medicare All Medicare |
$9.80
|
| Rate for Payer: Monida Allegiance |
$13.30
|
| Rate for Payer: Monida First Choice Health |
$13.58
|
| Rate for Payer: Monida Montana Health Co-op |
$13.30
|
| Rate for Payer: Monida PacificSource |
$13.30
|
|
|
ALDOSTERONE (004374)
|
Facility
|
OP
|
$55.00
|
|
|
Service Code
|
CPT 82088
|
| Hospital Charge Code |
4082088
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$38.50 |
| Max. Negotiated Rate |
$55.00 |
| Rate for Payer: Aetna Commercial |
$52.25
|
| Rate for Payer: Aetna Medicare |
$49.50
|
| Rate for Payer: BCBS MT CHIP |
$49.50
|
| Rate for Payer: BCBS MT Closed Plan Network |
$52.25
|
| Rate for Payer: BCBS MT HealthLink |
$49.50
|
| Rate for Payer: BCBS MT Medicare |
$49.50
|
| Rate for Payer: BCBS MT POS |
$52.25
|
| Rate for Payer: BCBS MT Traditional |
$55.00
|
| Rate for Payer: Cash Price |
$49.50
|
| Rate for Payer: Cigna Commercial |
$52.25
|
| Rate for Payer: Cigna Medicare |
$49.50
|
| Rate for Payer: Medicaid All Medicaid |
$50.60
|
| Rate for Payer: Medicare All Medicare |
$38.50
|
| Rate for Payer: Monida Allegiance |
$52.25
|
| Rate for Payer: Monida First Choice Health |
$53.35
|
| Rate for Payer: Monida Montana Health Co-op |
$52.25
|
| Rate for Payer: Monida PacificSource |
$52.25
|
|
|
ALDOSTERONE (004374)
|
Facility
|
IP
|
$55.00
|
|
|
Service Code
|
CPT 82088
|
| Hospital Charge Code |
4082088
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$38.50 |
| Max. Negotiated Rate |
$55.00 |
| Rate for Payer: Aetna Commercial |
$52.25
|
| Rate for Payer: Aetna Medicare |
$49.50
|
| Rate for Payer: BCBS MT CHIP |
$49.50
|
| Rate for Payer: BCBS MT Closed Plan Network |
$52.25
|
| Rate for Payer: BCBS MT HealthLink |
$49.50
|
| Rate for Payer: BCBS MT Medicare |
$49.50
|
| Rate for Payer: BCBS MT POS |
$52.25
|
| Rate for Payer: BCBS MT Traditional |
$55.00
|
| Rate for Payer: Cash Price |
$49.50
|
| Rate for Payer: Cigna Commercial |
$52.25
|
| Rate for Payer: Cigna Medicare |
$49.50
|
| Rate for Payer: Medicaid All Medicaid |
$50.60
|
| Rate for Payer: Medicare All Medicare |
$38.50
|
| Rate for Payer: Monida Allegiance |
$52.25
|
| Rate for Payer: Monida First Choice Health |
$53.35
|
| Rate for Payer: Monida Montana Health Co-op |
$52.25
|
| Rate for Payer: Monida PacificSource |
$52.25
|
|
|
ALENDRONATE TAB [70 MG]
|
Facility
|
OP
|
$66.00
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
3000016
|
|
Hospital Revenue Code
|
250
|
| 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
|
|
|
ALENDRONATE TAB [70 MG]
|
Facility
|
IP
|
$66.00
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
3000016
|
|
Hospital Revenue Code
|
250
|
| 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
|
|
|
ALFUZOSIN ER TAB [10 MG] NF
|
Facility
|
IP
|
$14.00
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
3000017
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.80 |
| Max. Negotiated Rate |
$14.00 |
| Rate for Payer: Aetna Commercial |
$13.30
|
| Rate for Payer: Aetna Medicare |
$12.60
|
| Rate for Payer: BCBS MT CHIP |
$12.60
|
| Rate for Payer: BCBS MT Closed Plan Network |
$13.30
|
| Rate for Payer: BCBS MT HealthLink |
$12.60
|
| Rate for Payer: BCBS MT Medicare |
$12.60
|
| Rate for Payer: BCBS MT POS |
$13.30
|
| Rate for Payer: BCBS MT Traditional |
$14.00
|
| Rate for Payer: Cash Price |
$12.60
|
| Rate for Payer: Cigna Commercial |
$13.30
|
| Rate for Payer: Cigna Medicare |
$12.60
|
| Rate for Payer: Medicaid All Medicaid |
$12.88
|
| Rate for Payer: Medicare All Medicare |
$9.80
|
| Rate for Payer: Monida Allegiance |
$13.30
|
| Rate for Payer: Monida First Choice Health |
$13.58
|
| Rate for Payer: Monida Montana Health Co-op |
$13.30
|
| Rate for Payer: Monida PacificSource |
$13.30
|
|
|
ALFUZOSIN ER TAB [10 MG] NF
|
Facility
|
OP
|
$14.00
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
3000017
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.80 |
| Max. Negotiated Rate |
$14.00 |
| Rate for Payer: Aetna Commercial |
$13.30
|
| Rate for Payer: Aetna Medicare |
$12.60
|
| Rate for Payer: BCBS MT CHIP |
$12.60
|
| Rate for Payer: BCBS MT Closed Plan Network |
$13.30
|
| Rate for Payer: BCBS MT HealthLink |
$12.60
|
| Rate for Payer: BCBS MT Medicare |
$12.60
|
| Rate for Payer: BCBS MT POS |
$13.30
|
| Rate for Payer: BCBS MT Traditional |
$14.00
|
| Rate for Payer: Cash Price |
$12.60
|
| Rate for Payer: Cigna Commercial |
$13.30
|
| Rate for Payer: Cigna Medicare |
$12.60
|
| Rate for Payer: Medicaid All Medicaid |
$12.88
|
| Rate for Payer: Medicare All Medicare |
$9.80
|
| Rate for Payer: Monida Allegiance |
$13.30
|
| Rate for Payer: Monida First Choice Health |
$13.58
|
| Rate for Payer: Monida Montana Health Co-op |
$13.30
|
| Rate for Payer: Monida PacificSource |
$13.30
|
|
|
.ALKALINE PHOS ISOENZYMES (001612)
|
Facility
|
OP
|
$58.00
|
|
|
Service Code
|
CPT 84075
|
| Hospital Charge Code |
4040800
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$40.60 |
| Max. Negotiated Rate |
$58.00 |
| Rate for Payer: Aetna Commercial |
$55.10
|
| Rate for Payer: Aetna Medicare |
$52.20
|
| Rate for Payer: BCBS MT CHIP |
$52.20
|
| Rate for Payer: BCBS MT Closed Plan Network |
$55.10
|
| Rate for Payer: BCBS MT HealthLink |
$52.20
|
| Rate for Payer: BCBS MT Medicare |
$52.20
|
| Rate for Payer: BCBS MT POS |
$55.10
|
| Rate for Payer: BCBS MT Traditional |
$58.00
|
| Rate for Payer: Cash Price |
$52.20
|
| Rate for Payer: Cigna Commercial |
$55.10
|
| Rate for Payer: Cigna Medicare |
$52.20
|
| Rate for Payer: Medicaid All Medicaid |
$53.36
|
| Rate for Payer: Medicare All Medicare |
$40.60
|
| Rate for Payer: Monida Allegiance |
$55.10
|
| Rate for Payer: Monida First Choice Health |
$56.26
|
| Rate for Payer: Monida Montana Health Co-op |
$55.10
|
| Rate for Payer: Monida PacificSource |
$55.10
|
|
|
.ALKALINE PHOS ISOENZYMES (001612)
|
Facility
|
IP
|
$58.00
|
|
|
Service Code
|
CPT 84075
|
| Hospital Charge Code |
4040800
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$40.60 |
| Max. Negotiated Rate |
$58.00 |
| Rate for Payer: Aetna Commercial |
$55.10
|
| Rate for Payer: Aetna Medicare |
$52.20
|
| Rate for Payer: BCBS MT CHIP |
$52.20
|
| Rate for Payer: BCBS MT Closed Plan Network |
$55.10
|
| Rate for Payer: BCBS MT HealthLink |
$52.20
|
| Rate for Payer: BCBS MT Medicare |
$52.20
|
| Rate for Payer: BCBS MT POS |
$55.10
|
| Rate for Payer: BCBS MT Traditional |
$58.00
|
| Rate for Payer: Cash Price |
$52.20
|
| Rate for Payer: Cigna Commercial |
$55.10
|
| Rate for Payer: Cigna Medicare |
$52.20
|
| Rate for Payer: Medicaid All Medicaid |
$53.36
|
| Rate for Payer: Medicare All Medicare |
$40.60
|
| Rate for Payer: Monida Allegiance |
$55.10
|
| Rate for Payer: Monida First Choice Health |
$56.26
|
| Rate for Payer: Monida Montana Health Co-op |
$55.10
|
| Rate for Payer: Monida PacificSource |
$55.10
|
|
|
ALKALINE PHOSPHATASE
|
Facility
|
IP
|
$59.00
|
|
|
Service Code
|
CPT 84080
|
| Hospital Charge Code |
4084080
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$41.30 |
| Max. Negotiated Rate |
$59.00 |
| Rate for Payer: Aetna Commercial |
$56.05
|
| Rate for Payer: Aetna Medicare |
$53.10
|
| Rate for Payer: BCBS MT CHIP |
$53.10
|
| Rate for Payer: BCBS MT Closed Plan Network |
$56.05
|
| Rate for Payer: BCBS MT HealthLink |
$53.10
|
| Rate for Payer: BCBS MT Medicare |
$53.10
|
| Rate for Payer: BCBS MT POS |
$56.05
|
| Rate for Payer: BCBS MT Traditional |
$59.00
|
| Rate for Payer: Cash Price |
$53.10
|
| Rate for Payer: Cigna Commercial |
$56.05
|
| Rate for Payer: Cigna Medicare |
$53.10
|
| Rate for Payer: Medicaid All Medicaid |
$54.28
|
| Rate for Payer: Medicare All Medicare |
$41.30
|
| Rate for Payer: Monida Allegiance |
$56.05
|
| Rate for Payer: Monida First Choice Health |
$57.23
|
| Rate for Payer: Monida Montana Health Co-op |
$56.05
|
| Rate for Payer: Monida PacificSource |
$56.05
|
|
|
ALKALINE PHOSPHATASE
|
Facility
|
OP
|
$59.00
|
|
|
Service Code
|
CPT 84080
|
| Hospital Charge Code |
4084080
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$41.30 |
| Max. Negotiated Rate |
$59.00 |
| Rate for Payer: Aetna Commercial |
$56.05
|
| Rate for Payer: Aetna Medicare |
$53.10
|
| Rate for Payer: BCBS MT CHIP |
$53.10
|
| Rate for Payer: BCBS MT Closed Plan Network |
$56.05
|
| Rate for Payer: BCBS MT HealthLink |
$53.10
|
| Rate for Payer: BCBS MT Medicare |
$53.10
|
| Rate for Payer: BCBS MT POS |
$56.05
|
| Rate for Payer: BCBS MT Traditional |
$59.00
|
| Rate for Payer: Cash Price |
$53.10
|
| Rate for Payer: Cigna Commercial |
$56.05
|
| Rate for Payer: Cigna Medicare |
$53.10
|
| Rate for Payer: Medicaid All Medicaid |
$54.28
|
| Rate for Payer: Medicare All Medicare |
$41.30
|
| Rate for Payer: Monida Allegiance |
$56.05
|
| Rate for Payer: Monida First Choice Health |
$57.23
|
| Rate for Payer: Monida Montana Health Co-op |
$56.05
|
| Rate for Payer: Monida PacificSource |
$56.05
|
|
|
.ALKALINE PHOS TOTAL (001612)
|
Facility
|
IP
|
$58.00
|
|
|
Service Code
|
CPT 84075
|
| Hospital Charge Code |
4084075
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$40.60 |
| Max. Negotiated Rate |
$58.00 |
| Rate for Payer: Aetna Commercial |
$55.10
|
| Rate for Payer: Aetna Medicare |
$52.20
|
| Rate for Payer: BCBS MT CHIP |
$52.20
|
| Rate for Payer: BCBS MT Closed Plan Network |
$55.10
|
| Rate for Payer: BCBS MT HealthLink |
$52.20
|
| Rate for Payer: BCBS MT Medicare |
$52.20
|
| Rate for Payer: BCBS MT POS |
$55.10
|
| Rate for Payer: BCBS MT Traditional |
$58.00
|
| Rate for Payer: Cash Price |
$52.20
|
| Rate for Payer: Cigna Commercial |
$55.10
|
| Rate for Payer: Cigna Medicare |
$52.20
|
| Rate for Payer: Medicaid All Medicaid |
$53.36
|
| Rate for Payer: Medicare All Medicare |
$40.60
|
| Rate for Payer: Monida Allegiance |
$55.10
|
| Rate for Payer: Monida First Choice Health |
$56.26
|
| Rate for Payer: Monida Montana Health Co-op |
$55.10
|
| Rate for Payer: Monida PacificSource |
$55.10
|
|
|
.ALKALINE PHOS TOTAL (001612)
|
Facility
|
OP
|
$58.00
|
|
|
Service Code
|
CPT 84075
|
| Hospital Charge Code |
4084075
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$40.60 |
| Max. Negotiated Rate |
$58.00 |
| Rate for Payer: Aetna Commercial |
$55.10
|
| Rate for Payer: Aetna Medicare |
$52.20
|
| Rate for Payer: BCBS MT CHIP |
$52.20
|
| Rate for Payer: BCBS MT Closed Plan Network |
$55.10
|
| Rate for Payer: BCBS MT HealthLink |
$52.20
|
| Rate for Payer: BCBS MT Medicare |
$52.20
|
| Rate for Payer: BCBS MT POS |
$55.10
|
| Rate for Payer: BCBS MT Traditional |
$58.00
|
| Rate for Payer: Cash Price |
$52.20
|
| Rate for Payer: Cigna Commercial |
$55.10
|
| Rate for Payer: Cigna Medicare |
$52.20
|
| Rate for Payer: Medicaid All Medicaid |
$53.36
|
| Rate for Payer: Medicare All Medicare |
$40.60
|
| Rate for Payer: Monida Allegiance |
$55.10
|
| Rate for Payer: Monida First Choice Health |
$56.26
|
| Rate for Payer: Monida Montana Health Co-op |
$55.10
|
| Rate for Payer: Monida PacificSource |
$55.10
|
|
|
.ALLERGEN SPECIFIC IGE
|
Facility
|
IP
|
$56.00
|
|
|
Service Code
|
CPT 86003
|
| Hospital Charge Code |
4086003
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$39.20 |
| Max. Negotiated Rate |
$56.00 |
| Rate for Payer: Aetna Commercial |
$53.20
|
| Rate for Payer: Aetna Medicare |
$50.40
|
| Rate for Payer: BCBS MT CHIP |
$50.40
|
| Rate for Payer: BCBS MT Closed Plan Network |
$53.20
|
| Rate for Payer: BCBS MT HealthLink |
$50.40
|
| Rate for Payer: BCBS MT Medicare |
$50.40
|
| Rate for Payer: BCBS MT POS |
$53.20
|
| Rate for Payer: BCBS MT Traditional |
$56.00
|
| Rate for Payer: Cash Price |
$50.40
|
| Rate for Payer: Cigna Commercial |
$53.20
|
| Rate for Payer: Cigna Medicare |
$50.40
|
| Rate for Payer: Medicaid All Medicaid |
$51.52
|
| Rate for Payer: Medicare All Medicare |
$39.20
|
| Rate for Payer: Monida Allegiance |
$53.20
|
| Rate for Payer: Monida First Choice Health |
$54.32
|
| Rate for Payer: Monida Montana Health Co-op |
$53.20
|
| Rate for Payer: Monida PacificSource |
$53.20
|
|
|
.ALLERGEN SPECIFIC IGE
|
Facility
|
OP
|
$56.00
|
|
|
Service Code
|
CPT 86003
|
| Hospital Charge Code |
4086003
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$39.20 |
| Max. Negotiated Rate |
$56.00 |
| Rate for Payer: Aetna Commercial |
$53.20
|
| Rate for Payer: Aetna Medicare |
$50.40
|
| Rate for Payer: BCBS MT CHIP |
$50.40
|
| Rate for Payer: BCBS MT Closed Plan Network |
$53.20
|
| Rate for Payer: BCBS MT HealthLink |
$50.40
|
| Rate for Payer: BCBS MT Medicare |
$50.40
|
| Rate for Payer: BCBS MT POS |
$53.20
|
| Rate for Payer: BCBS MT Traditional |
$56.00
|
| Rate for Payer: Cash Price |
$50.40
|
| Rate for Payer: Cigna Commercial |
$53.20
|
| Rate for Payer: Cigna Medicare |
$50.40
|
| Rate for Payer: Medicaid All Medicaid |
$51.52
|
| Rate for Payer: Medicare All Medicare |
$39.20
|
| Rate for Payer: Monida Allegiance |
$53.20
|
| Rate for Payer: Monida First Choice Health |
$54.32
|
| Rate for Payer: Monida Montana Health Co-op |
$53.20
|
| Rate for Payer: Monida PacificSource |
$53.20
|
|
|
ALLERGEN SPECIFIC IGG QUAN/SEMIQUAN EA
|
Facility
|
OP
|
$323.18
|
|
|
Service Code
|
CPT 86001
|
| Hospital Charge Code |
4086001
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$226.23 |
| Max. Negotiated Rate |
$323.18 |
| Rate for Payer: Aetna Commercial |
$307.02
|
| Rate for Payer: Aetna Medicare |
$290.86
|
| Rate for Payer: BCBS MT CHIP |
$290.86
|
| Rate for Payer: BCBS MT Closed Plan Network |
$307.02
|
| Rate for Payer: BCBS MT HealthLink |
$290.86
|
| Rate for Payer: BCBS MT Medicare |
$290.86
|
| Rate for Payer: BCBS MT POS |
$307.02
|
| Rate for Payer: BCBS MT Traditional |
$323.18
|
| Rate for Payer: Cash Price |
$290.86
|
| Rate for Payer: Cigna Commercial |
$307.02
|
| Rate for Payer: Cigna Medicare |
$290.86
|
| Rate for Payer: Medicaid All Medicaid |
$297.33
|
| Rate for Payer: Medicare All Medicare |
$226.23
|
| Rate for Payer: Monida Allegiance |
$307.02
|
| Rate for Payer: Monida First Choice Health |
$313.48
|
| Rate for Payer: Monida Montana Health Co-op |
$307.02
|
| Rate for Payer: Monida PacificSource |
$307.02
|
|
|
ALLERGEN SPECIFIC IGG QUAN/SEMIQUAN EA
|
Facility
|
IP
|
$323.18
|
|
|
Service Code
|
CPT 86001
|
| Hospital Charge Code |
4086001
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$226.23 |
| Max. Negotiated Rate |
$323.18 |
| Rate for Payer: Aetna Commercial |
$307.02
|
| Rate for Payer: Aetna Medicare |
$290.86
|
| Rate for Payer: BCBS MT CHIP |
$290.86
|
| Rate for Payer: BCBS MT Closed Plan Network |
$307.02
|
| Rate for Payer: BCBS MT HealthLink |
$290.86
|
| Rate for Payer: BCBS MT Medicare |
$290.86
|
| Rate for Payer: BCBS MT POS |
$307.02
|
| Rate for Payer: BCBS MT Traditional |
$323.18
|
| Rate for Payer: Cash Price |
$290.86
|
| Rate for Payer: Cigna Commercial |
$307.02
|
| Rate for Payer: Cigna Medicare |
$290.86
|
| Rate for Payer: Medicaid All Medicaid |
$297.33
|
| Rate for Payer: Medicare All Medicare |
$226.23
|
| Rate for Payer: Monida Allegiance |
$307.02
|
| Rate for Payer: Monida First Choice Health |
$313.48
|
| Rate for Payer: Monida Montana Health Co-op |
$307.02
|
| Rate for Payer: Monida PacificSource |
$307.02
|
|
|
ALLOPURINOL TAB [100 MG]
|
Facility
|
OP
|
$8.00
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
3000018
|
|
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
|
|
|
ALLOPURINOL TAB [100 MG]
|
Facility
|
IP
|
$8.00
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
3000018
|
|
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
|
|
|
ALLOPURINOL TAB [300 MG] NF
|
Facility
|
OP
|
$8.00
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
3007373
|
|
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
|
|
|
ALLOPURINOL TAB [300 MG] NF
|
Facility
|
IP
|
$8.00
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
3007373
|
|
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
|
|
|
.ALPHA-1-ANTITRYPSIN
|
Facility
|
IP
|
$81.00
|
|
|
Service Code
|
CPT 82103
|
| Hospital Charge Code |
4082103
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$56.70 |
| Max. Negotiated Rate |
$81.00 |
| Rate for Payer: Aetna Commercial |
$76.95
|
| Rate for Payer: Aetna Medicare |
$72.90
|
| Rate for Payer: BCBS MT CHIP |
$72.90
|
| Rate for Payer: BCBS MT Closed Plan Network |
$76.95
|
| Rate for Payer: BCBS MT HealthLink |
$72.90
|
| Rate for Payer: BCBS MT Medicare |
$72.90
|
| Rate for Payer: BCBS MT POS |
$76.95
|
| Rate for Payer: BCBS MT Traditional |
$81.00
|
| Rate for Payer: Cash Price |
$72.90
|
| Rate for Payer: Cigna Commercial |
$76.95
|
| Rate for Payer: Cigna Medicare |
$72.90
|
| Rate for Payer: Medicaid All Medicaid |
$74.52
|
| Rate for Payer: Medicare All Medicare |
$56.70
|
| Rate for Payer: Monida Allegiance |
$76.95
|
| Rate for Payer: Monida First Choice Health |
$78.57
|
| Rate for Payer: Monida Montana Health Co-op |
$76.95
|
| Rate for Payer: Monida PacificSource |
$76.95
|
|
|
.ALPHA-1-ANTITRYPSIN
|
Facility
|
OP
|
$81.00
|
|
|
Service Code
|
CPT 82103
|
| Hospital Charge Code |
4082103
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$56.70 |
| Max. Negotiated Rate |
$81.00 |
| Rate for Payer: Aetna Commercial |
$76.95
|
| Rate for Payer: Aetna Medicare |
$72.90
|
| Rate for Payer: BCBS MT CHIP |
$72.90
|
| Rate for Payer: BCBS MT Closed Plan Network |
$76.95
|
| Rate for Payer: BCBS MT HealthLink |
$72.90
|
| Rate for Payer: BCBS MT Medicare |
$72.90
|
| Rate for Payer: BCBS MT POS |
$76.95
|
| Rate for Payer: BCBS MT Traditional |
$81.00
|
| Rate for Payer: Cash Price |
$72.90
|
| Rate for Payer: Cigna Commercial |
$76.95
|
| Rate for Payer: Cigna Medicare |
$72.90
|
| Rate for Payer: Medicaid All Medicaid |
$74.52
|
| Rate for Payer: Medicare All Medicare |
$56.70
|
| Rate for Payer: Monida Allegiance |
$76.95
|
| Rate for Payer: Monida First Choice Health |
$78.57
|
| Rate for Payer: Monida Montana Health Co-op |
$76.95
|
| Rate for Payer: Monida PacificSource |
$76.95
|
|
|
.ALPHA-1-ANTITRYPSIN PHENOTYPE
|
Facility
|
IP
|
$81.00
|
|
|
Service Code
|
CPT 82104
|
| Hospital Charge Code |
4082104
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$56.70 |
| Max. Negotiated Rate |
$81.00 |
| Rate for Payer: Aetna Commercial |
$76.95
|
| Rate for Payer: Aetna Medicare |
$72.90
|
| Rate for Payer: BCBS MT CHIP |
$72.90
|
| Rate for Payer: BCBS MT Closed Plan Network |
$76.95
|
| Rate for Payer: BCBS MT HealthLink |
$72.90
|
| Rate for Payer: BCBS MT Medicare |
$72.90
|
| Rate for Payer: BCBS MT POS |
$76.95
|
| Rate for Payer: BCBS MT Traditional |
$81.00
|
| Rate for Payer: Cash Price |
$72.90
|
| Rate for Payer: Cigna Commercial |
$76.95
|
| Rate for Payer: Cigna Medicare |
$72.90
|
| Rate for Payer: Medicaid All Medicaid |
$74.52
|
| Rate for Payer: Medicare All Medicare |
$56.70
|
| Rate for Payer: Monida Allegiance |
$76.95
|
| Rate for Payer: Monida First Choice Health |
$78.57
|
| Rate for Payer: Monida Montana Health Co-op |
$76.95
|
| Rate for Payer: Monida PacificSource |
$76.95
|
|
|
.ALPHA-1-ANTITRYPSIN PHENOTYPE
|
Facility
|
OP
|
$81.00
|
|
|
Service Code
|
CPT 82104
|
| Hospital Charge Code |
4082104
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$56.70 |
| Max. Negotiated Rate |
$81.00 |
| Rate for Payer: Aetna Commercial |
$76.95
|
| Rate for Payer: Aetna Medicare |
$72.90
|
| Rate for Payer: BCBS MT CHIP |
$72.90
|
| Rate for Payer: BCBS MT Closed Plan Network |
$76.95
|
| Rate for Payer: BCBS MT HealthLink |
$72.90
|
| Rate for Payer: BCBS MT Medicare |
$72.90
|
| Rate for Payer: BCBS MT POS |
$76.95
|
| Rate for Payer: BCBS MT Traditional |
$81.00
|
| Rate for Payer: Cash Price |
$72.90
|
| Rate for Payer: Cigna Commercial |
$76.95
|
| Rate for Payer: Cigna Medicare |
$72.90
|
| Rate for Payer: Medicaid All Medicaid |
$74.52
|
| Rate for Payer: Medicare All Medicare |
$56.70
|
| Rate for Payer: Monida Allegiance |
$76.95
|
| Rate for Payer: Monida First Choice Health |
$78.57
|
| Rate for Payer: Monida Montana Health Co-op |
$76.95
|
| Rate for Payer: Monida PacificSource |
$76.95
|
|
