|
GRIPPER PLUS 19 X .75"
|
Facility
|
IP
|
$32.00
|
|
| Hospital Charge Code |
80030231
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$22.40 |
| Max. Negotiated Rate |
$32.00 |
| Rate for Payer: Aetna Commercial |
$30.40
|
| Rate for Payer: Aetna Medicare |
$28.80
|
| Rate for Payer: BCBS MT CHIP |
$28.80
|
| Rate for Payer: BCBS MT Closed Plan Network |
$30.40
|
| Rate for Payer: BCBS MT HealthLink |
$28.80
|
| Rate for Payer: BCBS MT Medicare |
$28.80
|
| Rate for Payer: BCBS MT POS |
$30.40
|
| Rate for Payer: BCBS MT Traditional |
$32.00
|
| Rate for Payer: Cash Price |
$28.80
|
| Rate for Payer: Cigna Commercial |
$30.40
|
| Rate for Payer: Cigna Medicare |
$28.80
|
| Rate for Payer: Medicaid All Medicaid |
$29.44
|
| Rate for Payer: Medicare All Medicare |
$22.40
|
| Rate for Payer: Monida Allegiance |
$30.40
|
| Rate for Payer: Monida First Choice Health |
$31.04
|
| Rate for Payer: Monida Montana Health Co-op |
$30.40
|
| Rate for Payer: Monida PacificSource |
$30.40
|
|
|
GROUP A STREP CULTURE (008169)
|
Facility
|
IP
|
$13.00
|
|
|
Service Code
|
HCPCS 87081
|
| Hospital Charge Code |
4087081
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$9.10 |
| Max. Negotiated Rate |
$13.00 |
| Rate for Payer: Aetna Commercial |
$12.35
|
| Rate for Payer: Aetna Medicare |
$11.70
|
| Rate for Payer: BCBS MT CHIP |
$11.70
|
| Rate for Payer: BCBS MT Closed Plan Network |
$12.35
|
| Rate for Payer: BCBS MT HealthLink |
$11.70
|
| Rate for Payer: BCBS MT Medicare |
$11.70
|
| Rate for Payer: BCBS MT POS |
$12.35
|
| Rate for Payer: BCBS MT Traditional |
$13.00
|
| Rate for Payer: Cash Price |
$11.70
|
| Rate for Payer: Cigna Commercial |
$12.35
|
| Rate for Payer: Cigna Medicare |
$11.70
|
| Rate for Payer: Medicaid All Medicaid |
$11.96
|
| Rate for Payer: Medicare All Medicare |
$9.10
|
| Rate for Payer: Monida Allegiance |
$12.35
|
| Rate for Payer: Monida First Choice Health |
$12.61
|
| Rate for Payer: Monida Montana Health Co-op |
$12.35
|
| Rate for Payer: Monida PacificSource |
$12.35
|
|
|
GROUP A STREP CULTURE (008169)
|
Facility
|
OP
|
$13.00
|
|
|
Service Code
|
HCPCS 87081
|
| Hospital Charge Code |
4087081
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$9.10 |
| Max. Negotiated Rate |
$13.00 |
| Rate for Payer: Aetna Commercial |
$12.35
|
| Rate for Payer: Aetna Medicare |
$11.70
|
| Rate for Payer: BCBS MT CHIP |
$11.70
|
| Rate for Payer: BCBS MT Closed Plan Network |
$12.35
|
| Rate for Payer: BCBS MT HealthLink |
$11.70
|
| Rate for Payer: BCBS MT Medicare |
$11.70
|
| Rate for Payer: BCBS MT POS |
$12.35
|
| Rate for Payer: BCBS MT Traditional |
$13.00
|
| Rate for Payer: Cash Price |
$11.70
|
| Rate for Payer: Cigna Commercial |
$12.35
|
| Rate for Payer: Cigna Medicare |
$11.70
|
| Rate for Payer: Medicaid All Medicaid |
$11.96
|
| Rate for Payer: Medicare All Medicare |
$9.10
|
| Rate for Payer: Monida Allegiance |
$12.35
|
| Rate for Payer: Monida First Choice Health |
$12.61
|
| Rate for Payer: Monida Montana Health Co-op |
$12.35
|
| Rate for Payer: Monida PacificSource |
$12.35
|
|
|
GROUP A STREP SCREEN, RAPID TEST
|
Facility
|
OP
|
$105.00
|
|
|
Service Code
|
HCPCS 87880
|
| Hospital Charge Code |
4087880
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$73.50 |
| Max. Negotiated Rate |
$105.00 |
| Rate for Payer: Aetna Commercial |
$99.75
|
| Rate for Payer: Aetna Medicare |
$94.50
|
| Rate for Payer: BCBS MT CHIP |
$94.50
|
| Rate for Payer: BCBS MT Closed Plan Network |
$99.75
|
| Rate for Payer: BCBS MT HealthLink |
$94.50
|
| Rate for Payer: BCBS MT Medicare |
$94.50
|
| Rate for Payer: BCBS MT POS |
$99.75
|
| Rate for Payer: BCBS MT Traditional |
$105.00
|
| Rate for Payer: Cash Price |
$94.50
|
| Rate for Payer: Cigna Commercial |
$99.75
|
| Rate for Payer: Cigna Medicare |
$94.50
|
| Rate for Payer: Medicaid All Medicaid |
$96.60
|
| Rate for Payer: Medicare All Medicare |
$73.50
|
| Rate for Payer: Monida Allegiance |
$99.75
|
| Rate for Payer: Monida First Choice Health |
$101.85
|
| Rate for Payer: Monida Montana Health Co-op |
$99.75
|
| Rate for Payer: Monida PacificSource |
$99.75
|
|
|
GROUP A STREP SCREEN, RAPID TEST
|
Facility
|
IP
|
$105.00
|
|
|
Service Code
|
HCPCS 87880
|
| Hospital Charge Code |
4087880
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$73.50 |
| Max. Negotiated Rate |
$105.00 |
| Rate for Payer: Aetna Commercial |
$99.75
|
| Rate for Payer: Aetna Medicare |
$94.50
|
| Rate for Payer: BCBS MT CHIP |
$94.50
|
| Rate for Payer: BCBS MT Closed Plan Network |
$99.75
|
| Rate for Payer: BCBS MT HealthLink |
$94.50
|
| Rate for Payer: BCBS MT Medicare |
$94.50
|
| Rate for Payer: BCBS MT POS |
$99.75
|
| Rate for Payer: BCBS MT Traditional |
$105.00
|
| Rate for Payer: Cash Price |
$94.50
|
| Rate for Payer: Cigna Commercial |
$99.75
|
| Rate for Payer: Cigna Medicare |
$94.50
|
| Rate for Payer: Medicaid All Medicaid |
$96.60
|
| Rate for Payer: Medicare All Medicare |
$73.50
|
| Rate for Payer: Monida Allegiance |
$99.75
|
| Rate for Payer: Monida First Choice Health |
$101.85
|
| Rate for Payer: Monida Montana Health Co-op |
$99.75
|
| Rate for Payer: Monida PacificSource |
$99.75
|
|
|
GUAIFEN/CODEINE LIQ [100MG/10MG 5ML] BTL
|
Facility
|
OP
|
$47.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
3000206
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$32.90 |
| Max. Negotiated Rate |
$47.00 |
| Rate for Payer: Aetna Commercial |
$44.65
|
| Rate for Payer: Aetna Medicare |
$42.30
|
| Rate for Payer: BCBS MT CHIP |
$42.30
|
| Rate for Payer: BCBS MT Closed Plan Network |
$44.65
|
| Rate for Payer: BCBS MT HealthLink |
$42.30
|
| Rate for Payer: BCBS MT Medicare |
$42.30
|
| Rate for Payer: BCBS MT POS |
$44.65
|
| Rate for Payer: BCBS MT Traditional |
$47.00
|
| Rate for Payer: Cash Price |
$42.30
|
| Rate for Payer: Cigna Commercial |
$44.65
|
| Rate for Payer: Cigna Medicare |
$42.30
|
| Rate for Payer: Medicaid All Medicaid |
$43.24
|
| Rate for Payer: Medicare All Medicare |
$32.90
|
| Rate for Payer: Monida Allegiance |
$44.65
|
| Rate for Payer: Monida First Choice Health |
$45.59
|
| Rate for Payer: Monida Montana Health Co-op |
$44.65
|
| Rate for Payer: Monida PacificSource |
$44.65
|
|
|
GUAIFEN/CODEINE LIQ [100MG/10MG 5ML] BTL
|
Facility
|
IP
|
$47.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
3000206
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$32.90 |
| Max. Negotiated Rate |
$47.00 |
| Rate for Payer: Aetna Commercial |
$44.65
|
| Rate for Payer: Aetna Medicare |
$42.30
|
| Rate for Payer: BCBS MT CHIP |
$42.30
|
| Rate for Payer: BCBS MT Closed Plan Network |
$44.65
|
| Rate for Payer: BCBS MT HealthLink |
$42.30
|
| Rate for Payer: BCBS MT Medicare |
$42.30
|
| Rate for Payer: BCBS MT POS |
$44.65
|
| Rate for Payer: BCBS MT Traditional |
$47.00
|
| Rate for Payer: Cash Price |
$42.30
|
| Rate for Payer: Cigna Commercial |
$44.65
|
| Rate for Payer: Cigna Medicare |
$42.30
|
| Rate for Payer: Medicaid All Medicaid |
$43.24
|
| Rate for Payer: Medicare All Medicare |
$32.90
|
| Rate for Payer: Monida Allegiance |
$44.65
|
| Rate for Payer: Monida First Choice Health |
$45.59
|
| Rate for Payer: Monida Montana Health Co-op |
$44.65
|
| Rate for Payer: Monida PacificSource |
$44.65
|
|
|
GUAIFEN/CODEINE UD CUP [100-10 MG/5 ML]
|
Facility
|
OP
|
$8.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
3000207
|
|
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
|
|
|
GUAIFEN/CODEINE UD CUP [100-10 MG/5 ML]
|
Facility
|
IP
|
$8.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
3000207
|
|
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
|
|
|
GUAIFENESIN ER TAB [600 MG]
|
Facility
|
OP
|
$8.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
3000208
|
|
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
|
|
|
GUAIFENESIN ER TAB [600 MG]
|
Facility
|
IP
|
$8.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
3000208
|
|
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
|
|
|
GUAIFENESIN LIQ [100 MG/5 ML] 118ML BTL
|
Facility
|
IP
|
$24.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
3000209
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$16.80 |
| Max. Negotiated Rate |
$24.00 |
| Rate for Payer: Aetna Commercial |
$22.80
|
| Rate for Payer: Aetna Medicare |
$21.60
|
| Rate for Payer: BCBS MT CHIP |
$21.60
|
| Rate for Payer: BCBS MT Closed Plan Network |
$22.80
|
| Rate for Payer: BCBS MT HealthLink |
$21.60
|
| Rate for Payer: BCBS MT Medicare |
$21.60
|
| Rate for Payer: BCBS MT POS |
$22.80
|
| Rate for Payer: BCBS MT Traditional |
$24.00
|
| Rate for Payer: Cash Price |
$21.60
|
| Rate for Payer: Cigna Commercial |
$22.80
|
| Rate for Payer: Cigna Medicare |
$21.60
|
| Rate for Payer: Medicaid All Medicaid |
$22.08
|
| Rate for Payer: Medicare All Medicare |
$16.80
|
| Rate for Payer: Monida Allegiance |
$22.80
|
| Rate for Payer: Monida First Choice Health |
$23.28
|
| Rate for Payer: Monida Montana Health Co-op |
$22.80
|
| Rate for Payer: Monida PacificSource |
$22.80
|
|
|
GUAIFENESIN LIQ [100 MG/5 ML] 118ML BTL
|
Facility
|
OP
|
$24.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
3000209
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$16.80 |
| Max. Negotiated Rate |
$24.00 |
| Rate for Payer: Aetna Commercial |
$22.80
|
| Rate for Payer: Aetna Medicare |
$21.60
|
| Rate for Payer: BCBS MT CHIP |
$21.60
|
| Rate for Payer: BCBS MT Closed Plan Network |
$22.80
|
| Rate for Payer: BCBS MT HealthLink |
$21.60
|
| Rate for Payer: BCBS MT Medicare |
$21.60
|
| Rate for Payer: BCBS MT POS |
$22.80
|
| Rate for Payer: BCBS MT Traditional |
$24.00
|
| Rate for Payer: Cash Price |
$21.60
|
| Rate for Payer: Cigna Commercial |
$22.80
|
| Rate for Payer: Cigna Medicare |
$21.60
|
| Rate for Payer: Medicaid All Medicaid |
$22.08
|
| Rate for Payer: Medicare All Medicare |
$16.80
|
| Rate for Payer: Monida Allegiance |
$22.80
|
| Rate for Payer: Monida First Choice Health |
$23.28
|
| Rate for Payer: Monida Montana Health Co-op |
$22.80
|
| Rate for Payer: Monida PacificSource |
$22.80
|
|
|
HALOPERIDOL INJ [5 MG/ML]
|
Facility
|
OP
|
$26.00
|
|
|
Service Code
|
HCPCS J1630
|
| Hospital Charge Code |
3000210
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$18.20 |
| Max. Negotiated Rate |
$26.00 |
| Rate for Payer: Aetna Commercial |
$24.70
|
| Rate for Payer: Aetna Medicare |
$23.40
|
| Rate for Payer: BCBS MT CHIP |
$23.40
|
| Rate for Payer: BCBS MT Closed Plan Network |
$24.70
|
| Rate for Payer: BCBS MT HealthLink |
$23.40
|
| Rate for Payer: BCBS MT Medicare |
$23.40
|
| Rate for Payer: BCBS MT POS |
$24.70
|
| Rate for Payer: BCBS MT Traditional |
$26.00
|
| Rate for Payer: Cash Price |
$23.40
|
| Rate for Payer: Cigna Commercial |
$24.70
|
| Rate for Payer: Cigna Medicare |
$23.40
|
| Rate for Payer: Medicaid All Medicaid |
$23.92
|
| Rate for Payer: Medicare All Medicare |
$18.20
|
| Rate for Payer: Monida Allegiance |
$24.70
|
| Rate for Payer: Monida First Choice Health |
$25.22
|
| Rate for Payer: Monida Montana Health Co-op |
$24.70
|
| Rate for Payer: Monida PacificSource |
$24.70
|
|
|
HALOPERIDOL INJ [5 MG/ML]
|
Facility
|
IP
|
$26.00
|
|
|
Service Code
|
HCPCS J1630
|
| Hospital Charge Code |
3000210
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$18.20 |
| Max. Negotiated Rate |
$26.00 |
| Rate for Payer: Aetna Commercial |
$24.70
|
| Rate for Payer: Aetna Medicare |
$23.40
|
| Rate for Payer: BCBS MT CHIP |
$23.40
|
| Rate for Payer: BCBS MT Closed Plan Network |
$24.70
|
| Rate for Payer: BCBS MT HealthLink |
$23.40
|
| Rate for Payer: BCBS MT Medicare |
$23.40
|
| Rate for Payer: BCBS MT POS |
$24.70
|
| Rate for Payer: BCBS MT Traditional |
$26.00
|
| Rate for Payer: Cash Price |
$23.40
|
| Rate for Payer: Cigna Commercial |
$24.70
|
| Rate for Payer: Cigna Medicare |
$23.40
|
| Rate for Payer: Medicaid All Medicaid |
$23.92
|
| Rate for Payer: Medicare All Medicare |
$18.20
|
| Rate for Payer: Monida Allegiance |
$24.70
|
| Rate for Payer: Monida First Choice Health |
$25.22
|
| Rate for Payer: Monida Montana Health Co-op |
$24.70
|
| Rate for Payer: Monida PacificSource |
$24.70
|
|
|
HALOPERIDOL TAB 1MG
|
Facility
|
OP
|
$8.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
3000211
|
|
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
|
|
|
HALOPERIDOL TAB 1MG
|
Facility
|
IP
|
$8.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
3000211
|
|
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
|
|
|
HANTAVIRUS ANTIBODIES, ELISA (835027)
|
Facility
|
OP
|
$212.00
|
|
|
Service Code
|
HCPCS 86790
|
| Hospital Charge Code |
4086790
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$148.40 |
| Max. Negotiated Rate |
$212.00 |
| Rate for Payer: Aetna Commercial |
$201.40
|
| Rate for Payer: Aetna Medicare |
$190.80
|
| Rate for Payer: BCBS MT CHIP |
$190.80
|
| Rate for Payer: BCBS MT Closed Plan Network |
$201.40
|
| Rate for Payer: BCBS MT HealthLink |
$190.80
|
| Rate for Payer: BCBS MT Medicare |
$190.80
|
| Rate for Payer: BCBS MT POS |
$201.40
|
| Rate for Payer: BCBS MT Traditional |
$212.00
|
| Rate for Payer: Cash Price |
$190.80
|
| Rate for Payer: Cigna Commercial |
$201.40
|
| Rate for Payer: Cigna Medicare |
$190.80
|
| Rate for Payer: Medicaid All Medicaid |
$195.04
|
| Rate for Payer: Medicare All Medicare |
$148.40
|
| Rate for Payer: Monida Allegiance |
$201.40
|
| Rate for Payer: Monida First Choice Health |
$205.64
|
| Rate for Payer: Monida Montana Health Co-op |
$201.40
|
| Rate for Payer: Monida PacificSource |
$201.40
|
|
|
HANTAVIRUS ANTIBODIES, ELISA (835027)
|
Facility
|
IP
|
$212.00
|
|
|
Service Code
|
HCPCS 86790
|
| Hospital Charge Code |
4086790
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$148.40 |
| Max. Negotiated Rate |
$212.00 |
| Rate for Payer: Aetna Commercial |
$201.40
|
| Rate for Payer: Aetna Medicare |
$190.80
|
| Rate for Payer: BCBS MT CHIP |
$190.80
|
| Rate for Payer: BCBS MT Closed Plan Network |
$201.40
|
| Rate for Payer: BCBS MT HealthLink |
$190.80
|
| Rate for Payer: BCBS MT Medicare |
$190.80
|
| Rate for Payer: BCBS MT POS |
$201.40
|
| Rate for Payer: BCBS MT Traditional |
$212.00
|
| Rate for Payer: Cash Price |
$190.80
|
| Rate for Payer: Cigna Commercial |
$201.40
|
| Rate for Payer: Cigna Medicare |
$190.80
|
| Rate for Payer: Medicaid All Medicaid |
$195.04
|
| Rate for Payer: Medicare All Medicare |
$148.40
|
| Rate for Payer: Monida Allegiance |
$201.40
|
| Rate for Payer: Monida First Choice Health |
$205.64
|
| Rate for Payer: Monida Montana Health Co-op |
$201.40
|
| Rate for Payer: Monida PacificSource |
$201.40
|
|
|
HAPTOGLOBIN (001628)
|
Facility
|
IP
|
$20.00
|
|
|
Service Code
|
HCPCS 83010
|
| Hospital Charge Code |
4083010
|
|
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
|
|
|
HAPTOGLOBIN (001628)
|
Facility
|
OP
|
$20.00
|
|
|
Service Code
|
HCPCS 83010
|
| Hospital Charge Code |
4083010
|
|
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
|
|
|
HCG, BETA, QUANTITATIVE (004416)
|
Facility
|
IP
|
$24.00
|
|
|
Service Code
|
HCPCS 84702
|
| Hospital Charge Code |
4084702
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$16.80 |
| Max. Negotiated Rate |
$24.00 |
| Rate for Payer: Aetna Commercial |
$22.80
|
| Rate for Payer: Aetna Medicare |
$21.60
|
| Rate for Payer: BCBS MT CHIP |
$21.60
|
| Rate for Payer: BCBS MT Closed Plan Network |
$22.80
|
| Rate for Payer: BCBS MT HealthLink |
$21.60
|
| Rate for Payer: BCBS MT Medicare |
$21.60
|
| Rate for Payer: BCBS MT POS |
$22.80
|
| Rate for Payer: BCBS MT Traditional |
$24.00
|
| Rate for Payer: Cash Price |
$21.60
|
| Rate for Payer: Cigna Commercial |
$22.80
|
| Rate for Payer: Cigna Medicare |
$21.60
|
| Rate for Payer: Medicaid All Medicaid |
$22.08
|
| Rate for Payer: Medicare All Medicare |
$16.80
|
| Rate for Payer: Monida Allegiance |
$22.80
|
| Rate for Payer: Monida First Choice Health |
$23.28
|
| Rate for Payer: Monida Montana Health Co-op |
$22.80
|
| Rate for Payer: Monida PacificSource |
$22.80
|
|
|
HCG, BETA, QUANTITATIVE (004416)
|
Facility
|
OP
|
$24.00
|
|
|
Service Code
|
HCPCS 84702
|
| Hospital Charge Code |
4084702
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$16.80 |
| Max. Negotiated Rate |
$24.00 |
| Rate for Payer: Aetna Commercial |
$22.80
|
| Rate for Payer: Aetna Medicare |
$21.60
|
| Rate for Payer: BCBS MT CHIP |
$21.60
|
| Rate for Payer: BCBS MT Closed Plan Network |
$22.80
|
| Rate for Payer: BCBS MT HealthLink |
$21.60
|
| Rate for Payer: BCBS MT Medicare |
$21.60
|
| Rate for Payer: BCBS MT POS |
$22.80
|
| Rate for Payer: BCBS MT Traditional |
$24.00
|
| Rate for Payer: Cash Price |
$21.60
|
| Rate for Payer: Cigna Commercial |
$22.80
|
| Rate for Payer: Cigna Medicare |
$21.60
|
| Rate for Payer: Medicaid All Medicaid |
$22.08
|
| Rate for Payer: Medicare All Medicare |
$16.80
|
| Rate for Payer: Monida Allegiance |
$22.80
|
| Rate for Payer: Monida First Choice Health |
$23.28
|
| Rate for Payer: Monida Montana Health Co-op |
$22.80
|
| Rate for Payer: Monida PacificSource |
$22.80
|
|
|
HCG, QUALITATIVE, URINE
|
Facility
|
IP
|
$103.00
|
|
|
Service Code
|
HCPCS 81025
|
| Hospital Charge Code |
4081025
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$72.10 |
| Max. Negotiated Rate |
$103.00 |
| Rate for Payer: Aetna Commercial |
$97.85
|
| Rate for Payer: Aetna Medicare |
$92.70
|
| Rate for Payer: BCBS MT CHIP |
$92.70
|
| Rate for Payer: BCBS MT Closed Plan Network |
$97.85
|
| Rate for Payer: BCBS MT HealthLink |
$92.70
|
| Rate for Payer: BCBS MT Medicare |
$92.70
|
| Rate for Payer: BCBS MT POS |
$97.85
|
| Rate for Payer: BCBS MT Traditional |
$103.00
|
| Rate for Payer: Cash Price |
$92.70
|
| Rate for Payer: Cigna Commercial |
$97.85
|
| Rate for Payer: Cigna Medicare |
$92.70
|
| Rate for Payer: Medicaid All Medicaid |
$94.76
|
| Rate for Payer: Medicare All Medicare |
$72.10
|
| Rate for Payer: Monida Allegiance |
$97.85
|
| Rate for Payer: Monida First Choice Health |
$99.91
|
| Rate for Payer: Monida Montana Health Co-op |
$97.85
|
| Rate for Payer: Monida PacificSource |
$97.85
|
|
|
HCG, QUALITATIVE, URINE
|
Facility
|
OP
|
$103.00
|
|
|
Service Code
|
HCPCS 81025
|
| Hospital Charge Code |
4081025
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$72.10 |
| Max. Negotiated Rate |
$103.00 |
| Rate for Payer: Aetna Commercial |
$97.85
|
| Rate for Payer: Aetna Medicare |
$92.70
|
| Rate for Payer: BCBS MT CHIP |
$92.70
|
| Rate for Payer: BCBS MT Closed Plan Network |
$97.85
|
| Rate for Payer: BCBS MT HealthLink |
$92.70
|
| Rate for Payer: BCBS MT Medicare |
$92.70
|
| Rate for Payer: BCBS MT POS |
$97.85
|
| Rate for Payer: BCBS MT Traditional |
$103.00
|
| Rate for Payer: Cash Price |
$92.70
|
| Rate for Payer: Cigna Commercial |
$97.85
|
| Rate for Payer: Cigna Medicare |
$92.70
|
| Rate for Payer: Medicaid All Medicaid |
$94.76
|
| Rate for Payer: Medicare All Medicare |
$72.10
|
| Rate for Payer: Monida Allegiance |
$97.85
|
| Rate for Payer: Monida First Choice Health |
$99.91
|
| Rate for Payer: Monida Montana Health Co-op |
$97.85
|
| Rate for Payer: Monida PacificSource |
$97.85
|
|
