|
FECAL FAT, QUALITATIVE, RANDOM (001677)
|
Facility
|
OP
|
$49.00
|
|
|
Service Code
|
HCPCS 82705
|
| Hospital Charge Code |
4082705
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$34.30 |
| Max. Negotiated Rate |
$49.00 |
| Rate for Payer: Aetna Commercial |
$46.55
|
| Rate for Payer: Aetna Medicare |
$44.10
|
| Rate for Payer: BCBS MT CHIP |
$44.10
|
| Rate for Payer: BCBS MT Closed Plan Network |
$46.55
|
| Rate for Payer: BCBS MT HealthLink |
$44.10
|
| Rate for Payer: BCBS MT Medicare |
$44.10
|
| Rate for Payer: BCBS MT POS |
$46.55
|
| Rate for Payer: BCBS MT Traditional |
$49.00
|
| Rate for Payer: Cash Price |
$44.10
|
| Rate for Payer: Cigna Commercial |
$46.55
|
| Rate for Payer: Cigna Medicare |
$44.10
|
| Rate for Payer: Medicaid All Medicaid |
$45.08
|
| Rate for Payer: Medicare All Medicare |
$34.30
|
| Rate for Payer: Monida Allegiance |
$46.55
|
| Rate for Payer: Monida First Choice Health |
$47.53
|
| Rate for Payer: Monida Montana Health Co-op |
$46.55
|
| Rate for Payer: Monida PacificSource |
$46.55
|
|
|
FECAL FAT, QUALITATIVE, RANDOM (001677)
|
Facility
|
IP
|
$49.00
|
|
|
Service Code
|
HCPCS 82705
|
| Hospital Charge Code |
4082705
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$34.30 |
| Max. Negotiated Rate |
$49.00 |
| Rate for Payer: Aetna Commercial |
$46.55
|
| Rate for Payer: Aetna Medicare |
$44.10
|
| Rate for Payer: BCBS MT CHIP |
$44.10
|
| Rate for Payer: BCBS MT Closed Plan Network |
$46.55
|
| Rate for Payer: BCBS MT HealthLink |
$44.10
|
| Rate for Payer: BCBS MT Medicare |
$44.10
|
| Rate for Payer: BCBS MT POS |
$46.55
|
| Rate for Payer: BCBS MT Traditional |
$49.00
|
| Rate for Payer: Cash Price |
$44.10
|
| Rate for Payer: Cigna Commercial |
$46.55
|
| Rate for Payer: Cigna Medicare |
$44.10
|
| Rate for Payer: Medicaid All Medicaid |
$45.08
|
| Rate for Payer: Medicare All Medicare |
$34.30
|
| Rate for Payer: Monida Allegiance |
$46.55
|
| Rate for Payer: Monida First Choice Health |
$47.53
|
| Rate for Payer: Monida Montana Health Co-op |
$46.55
|
| Rate for Payer: Monida PacificSource |
$46.55
|
|
|
FECAL FAT, QUANTITATIVE, 72 HR (001354)
|
Facility
|
OP
|
$73.00
|
|
|
Service Code
|
HCPCS 82710
|
| Hospital Charge Code |
4082710
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$51.10 |
| Max. Negotiated Rate |
$73.00 |
| Rate for Payer: Aetna Commercial |
$69.35
|
| Rate for Payer: Aetna Medicare |
$65.70
|
| Rate for Payer: BCBS MT CHIP |
$65.70
|
| Rate for Payer: BCBS MT Closed Plan Network |
$69.35
|
| Rate for Payer: BCBS MT HealthLink |
$65.70
|
| Rate for Payer: BCBS MT Medicare |
$65.70
|
| Rate for Payer: BCBS MT POS |
$69.35
|
| Rate for Payer: BCBS MT Traditional |
$73.00
|
| Rate for Payer: Cash Price |
$65.70
|
| Rate for Payer: Cigna Commercial |
$69.35
|
| Rate for Payer: Cigna Medicare |
$65.70
|
| Rate for Payer: Medicaid All Medicaid |
$67.16
|
| Rate for Payer: Medicare All Medicare |
$51.10
|
| Rate for Payer: Monida Allegiance |
$69.35
|
| Rate for Payer: Monida First Choice Health |
$70.81
|
| Rate for Payer: Monida Montana Health Co-op |
$69.35
|
| Rate for Payer: Monida PacificSource |
$69.35
|
|
|
FECAL FAT, QUANTITATIVE, 72 HR (001354)
|
Facility
|
IP
|
$73.00
|
|
|
Service Code
|
HCPCS 82710
|
| Hospital Charge Code |
4082710
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$51.10 |
| Max. Negotiated Rate |
$73.00 |
| Rate for Payer: Aetna Commercial |
$69.35
|
| Rate for Payer: Aetna Medicare |
$65.70
|
| Rate for Payer: BCBS MT CHIP |
$65.70
|
| Rate for Payer: BCBS MT Closed Plan Network |
$69.35
|
| Rate for Payer: BCBS MT HealthLink |
$65.70
|
| Rate for Payer: BCBS MT Medicare |
$65.70
|
| Rate for Payer: BCBS MT POS |
$69.35
|
| Rate for Payer: BCBS MT Traditional |
$73.00
|
| Rate for Payer: Cash Price |
$65.70
|
| Rate for Payer: Cigna Commercial |
$69.35
|
| Rate for Payer: Cigna Medicare |
$65.70
|
| Rate for Payer: Medicaid All Medicaid |
$67.16
|
| Rate for Payer: Medicare All Medicare |
$51.10
|
| Rate for Payer: Monida Allegiance |
$69.35
|
| Rate for Payer: Monida First Choice Health |
$70.81
|
| Rate for Payer: Monida Montana Health Co-op |
$69.35
|
| Rate for Payer: Monida PacificSource |
$69.35
|
|
|
FEEDING PUMP BAG
|
Facility
|
OP
|
$19.00
|
|
| Hospital Charge Code |
80030174
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$13.30 |
| Max. Negotiated Rate |
$19.00 |
| Rate for Payer: Aetna Commercial |
$18.05
|
| Rate for Payer: Aetna Medicare |
$17.10
|
| Rate for Payer: BCBS MT CHIP |
$17.10
|
| Rate for Payer: BCBS MT Closed Plan Network |
$18.05
|
| Rate for Payer: BCBS MT HealthLink |
$17.10
|
| Rate for Payer: BCBS MT Medicare |
$17.10
|
| Rate for Payer: BCBS MT POS |
$18.05
|
| Rate for Payer: BCBS MT Traditional |
$19.00
|
| Rate for Payer: Cash Price |
$17.10
|
| Rate for Payer: Cigna Commercial |
$18.05
|
| Rate for Payer: Cigna Medicare |
$17.10
|
| Rate for Payer: Medicaid All Medicaid |
$17.48
|
| Rate for Payer: Medicare All Medicare |
$13.30
|
| Rate for Payer: Monida Allegiance |
$18.05
|
| Rate for Payer: Monida First Choice Health |
$18.43
|
| Rate for Payer: Monida Montana Health Co-op |
$18.05
|
| Rate for Payer: Monida PacificSource |
$18.05
|
|
|
FEEDING PUMP BAG
|
Facility
|
IP
|
$19.00
|
|
| Hospital Charge Code |
80030174
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$13.30 |
| Max. Negotiated Rate |
$19.00 |
| Rate for Payer: Aetna Commercial |
$18.05
|
| Rate for Payer: Aetna Medicare |
$17.10
|
| Rate for Payer: BCBS MT CHIP |
$17.10
|
| Rate for Payer: BCBS MT Closed Plan Network |
$18.05
|
| Rate for Payer: BCBS MT HealthLink |
$17.10
|
| Rate for Payer: BCBS MT Medicare |
$17.10
|
| Rate for Payer: BCBS MT POS |
$18.05
|
| Rate for Payer: BCBS MT Traditional |
$19.00
|
| Rate for Payer: Cash Price |
$17.10
|
| Rate for Payer: Cigna Commercial |
$18.05
|
| Rate for Payer: Cigna Medicare |
$17.10
|
| Rate for Payer: Medicaid All Medicaid |
$17.48
|
| Rate for Payer: Medicare All Medicare |
$13.30
|
| Rate for Payer: Monida Allegiance |
$18.05
|
| Rate for Payer: Monida First Choice Health |
$18.43
|
| Rate for Payer: Monida Montana Health Co-op |
$18.05
|
| Rate for Payer: Monida PacificSource |
$18.05
|
|
|
FENTANYL 12 MCG
|
Facility
|
OP
|
$68.00
|
|
|
Service Code
|
HCPCS J3490 QN
|
| Hospital Charge Code |
649378
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$47.60 |
| Max. Negotiated Rate |
$68.00 |
| Rate for Payer: Aetna Commercial |
$64.60
|
| Rate for Payer: Aetna Medicare |
$61.20
|
| Rate for Payer: BCBS MT CHIP |
$61.20
|
| Rate for Payer: BCBS MT Closed Plan Network |
$64.60
|
| Rate for Payer: BCBS MT HealthLink |
$61.20
|
| Rate for Payer: BCBS MT Medicare |
$61.20
|
| Rate for Payer: BCBS MT POS |
$64.60
|
| Rate for Payer: BCBS MT Traditional |
$68.00
|
| Rate for Payer: Cash Price |
$61.20
|
| Rate for Payer: Cigna Commercial |
$64.60
|
| Rate for Payer: Cigna Medicare |
$61.20
|
| Rate for Payer: Medicaid All Medicaid |
$62.56
|
| Rate for Payer: Medicare All Medicare |
$47.60
|
| Rate for Payer: Monida Allegiance |
$64.60
|
| Rate for Payer: Monida First Choice Health |
$65.96
|
| Rate for Payer: Monida Montana Health Co-op |
$64.60
|
| Rate for Payer: Monida PacificSource |
$64.60
|
|
|
FENTANYL 12 MCG
|
Facility
|
IP
|
$68.00
|
|
|
Service Code
|
HCPCS J3490 QN
|
| Hospital Charge Code |
649378
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$47.60 |
| Max. Negotiated Rate |
$68.00 |
| Rate for Payer: Aetna Commercial |
$64.60
|
| Rate for Payer: Aetna Medicare |
$61.20
|
| Rate for Payer: BCBS MT CHIP |
$61.20
|
| Rate for Payer: BCBS MT Closed Plan Network |
$64.60
|
| Rate for Payer: BCBS MT HealthLink |
$61.20
|
| Rate for Payer: BCBS MT Medicare |
$61.20
|
| Rate for Payer: BCBS MT POS |
$64.60
|
| Rate for Payer: BCBS MT Traditional |
$68.00
|
| Rate for Payer: Cash Price |
$61.20
|
| Rate for Payer: Cigna Commercial |
$64.60
|
| Rate for Payer: Cigna Medicare |
$61.20
|
| Rate for Payer: Medicaid All Medicaid |
$62.56
|
| Rate for Payer: Medicare All Medicare |
$47.60
|
| Rate for Payer: Monida Allegiance |
$64.60
|
| Rate for Payer: Monida First Choice Health |
$65.96
|
| Rate for Payer: Monida Montana Health Co-op |
$64.60
|
| Rate for Payer: Monida PacificSource |
$64.60
|
|
|
FENTANYL 50 PATCH (MCG/HR)
|
Facility
|
IP
|
$89.00
|
|
|
Service Code
|
NDC 47781042611
|
| Hospital Charge Code |
3007169
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$62.30 |
| Max. Negotiated Rate |
$89.00 |
| Rate for Payer: Aetna Commercial |
$84.55
|
| Rate for Payer: Aetna Medicare |
$80.10
|
| Rate for Payer: BCBS MT CHIP |
$80.10
|
| Rate for Payer: BCBS MT Closed Plan Network |
$84.55
|
| Rate for Payer: BCBS MT HealthLink |
$80.10
|
| Rate for Payer: BCBS MT Medicare |
$80.10
|
| Rate for Payer: BCBS MT POS |
$84.55
|
| Rate for Payer: BCBS MT Traditional |
$89.00
|
| Rate for Payer: Cash Price |
$80.10
|
| Rate for Payer: Cigna Commercial |
$84.55
|
| Rate for Payer: Cigna Medicare |
$80.10
|
| Rate for Payer: Medicaid All Medicaid |
$81.88
|
| Rate for Payer: Medicare All Medicare |
$62.30
|
| Rate for Payer: Monida Allegiance |
$84.55
|
| Rate for Payer: Monida First Choice Health |
$86.33
|
| Rate for Payer: Monida Montana Health Co-op |
$84.55
|
| Rate for Payer: Monida PacificSource |
$84.55
|
|
|
FENTANYL 50 PATCH (MCG/HR)
|
Facility
|
OP
|
$89.00
|
|
|
Service Code
|
NDC 47781042611
|
| Hospital Charge Code |
3007169
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$62.30 |
| Max. Negotiated Rate |
$89.00 |
| Rate for Payer: Aetna Commercial |
$84.55
|
| Rate for Payer: Aetna Medicare |
$80.10
|
| Rate for Payer: BCBS MT CHIP |
$80.10
|
| Rate for Payer: BCBS MT Closed Plan Network |
$84.55
|
| Rate for Payer: BCBS MT HealthLink |
$80.10
|
| Rate for Payer: BCBS MT Medicare |
$80.10
|
| Rate for Payer: BCBS MT POS |
$84.55
|
| Rate for Payer: BCBS MT Traditional |
$89.00
|
| Rate for Payer: Cash Price |
$80.10
|
| Rate for Payer: Cigna Commercial |
$84.55
|
| Rate for Payer: Cigna Medicare |
$80.10
|
| Rate for Payer: Medicaid All Medicaid |
$81.88
|
| Rate for Payer: Medicare All Medicare |
$62.30
|
| Rate for Payer: Monida Allegiance |
$84.55
|
| Rate for Payer: Monida First Choice Health |
$86.33
|
| Rate for Payer: Monida Montana Health Co-op |
$84.55
|
| Rate for Payer: Monida PacificSource |
$84.55
|
|
|
FENTANYL INJ [100 MCG/ 2 ML] 2ML SDV
|
Facility
|
IP
|
$8.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
3000598
|
|
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
|
|
|
FENTANYL INJ [100 MCG/ 2 ML] 2ML SDV
|
Facility
|
OP
|
$8.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
3000598
|
|
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
|
|
|
FENTANYL INJ [50 MCG/ML] 1ML
|
Facility
|
OP
|
$8.00
|
|
|
Service Code
|
HCPCS J3010
|
| Hospital Charge Code |
3007342
|
|
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
|
|
|
FENTANYL INJ [50 MCG/ML] 1ML
|
Facility
|
IP
|
$8.00
|
|
|
Service Code
|
HCPCS J3010
|
| Hospital Charge Code |
3007342
|
|
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
|
|
|
FENTANYL INJ [50 MCG/ML] 2ML VIAL
|
Facility
|
IP
|
$26.00
|
|
|
Service Code
|
HCPCS J3010
|
| Hospital Charge Code |
3000175
|
|
Hospital Revenue Code
|
636
|
| 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
|
|
|
FENTANYL INJ [50 MCG/ML] 2ML VIAL
|
Facility
|
OP
|
$26.00
|
|
|
Service Code
|
HCPCS J3010
|
| Hospital Charge Code |
3000175
|
|
Hospital Revenue Code
|
636
|
| 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
|
|
|
FENTANYL PATCH [12 MCG/HR]
|
Facility
|
IP
|
$68.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
3000176
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$47.60 |
| Max. Negotiated Rate |
$68.00 |
| Rate for Payer: Aetna Commercial |
$64.60
|
| Rate for Payer: Aetna Medicare |
$61.20
|
| Rate for Payer: BCBS MT CHIP |
$61.20
|
| Rate for Payer: BCBS MT Closed Plan Network |
$64.60
|
| Rate for Payer: BCBS MT HealthLink |
$61.20
|
| Rate for Payer: BCBS MT Medicare |
$61.20
|
| Rate for Payer: BCBS MT POS |
$64.60
|
| Rate for Payer: BCBS MT Traditional |
$68.00
|
| Rate for Payer: Cash Price |
$61.20
|
| Rate for Payer: Cigna Commercial |
$64.60
|
| Rate for Payer: Cigna Medicare |
$61.20
|
| Rate for Payer: Medicaid All Medicaid |
$62.56
|
| Rate for Payer: Medicare All Medicare |
$47.60
|
| Rate for Payer: Monida Allegiance |
$64.60
|
| Rate for Payer: Monida First Choice Health |
$65.96
|
| Rate for Payer: Monida Montana Health Co-op |
$64.60
|
| Rate for Payer: Monida PacificSource |
$64.60
|
|
|
FENTANYL PATCH [12 MCG/HR]
|
Facility
|
OP
|
$68.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
3000176
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$47.60 |
| Max. Negotiated Rate |
$68.00 |
| Rate for Payer: Aetna Commercial |
$64.60
|
| Rate for Payer: Aetna Medicare |
$61.20
|
| Rate for Payer: BCBS MT CHIP |
$61.20
|
| Rate for Payer: BCBS MT Closed Plan Network |
$64.60
|
| Rate for Payer: BCBS MT HealthLink |
$61.20
|
| Rate for Payer: BCBS MT Medicare |
$61.20
|
| Rate for Payer: BCBS MT POS |
$64.60
|
| Rate for Payer: BCBS MT Traditional |
$68.00
|
| Rate for Payer: Cash Price |
$61.20
|
| Rate for Payer: Cigna Commercial |
$64.60
|
| Rate for Payer: Cigna Medicare |
$61.20
|
| Rate for Payer: Medicaid All Medicaid |
$62.56
|
| Rate for Payer: Medicare All Medicare |
$47.60
|
| Rate for Payer: Monida Allegiance |
$64.60
|
| Rate for Payer: Monida First Choice Health |
$65.96
|
| Rate for Payer: Monida Montana Health Co-op |
$64.60
|
| Rate for Payer: Monida PacificSource |
$64.60
|
|
|
FENTANYL PATCH [25 MCG/HR]
|
Facility
|
IP
|
$48.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
3000177
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$33.60 |
| Max. Negotiated Rate |
$48.00 |
| Rate for Payer: Aetna Commercial |
$45.60
|
| Rate for Payer: Aetna Medicare |
$43.20
|
| Rate for Payer: BCBS MT CHIP |
$43.20
|
| Rate for Payer: BCBS MT Closed Plan Network |
$45.60
|
| Rate for Payer: BCBS MT HealthLink |
$43.20
|
| Rate for Payer: BCBS MT Medicare |
$43.20
|
| Rate for Payer: BCBS MT POS |
$45.60
|
| Rate for Payer: BCBS MT Traditional |
$48.00
|
| Rate for Payer: Cash Price |
$43.20
|
| Rate for Payer: Cigna Commercial |
$45.60
|
| Rate for Payer: Cigna Medicare |
$43.20
|
| Rate for Payer: Medicaid All Medicaid |
$44.16
|
| Rate for Payer: Medicare All Medicare |
$33.60
|
| Rate for Payer: Monida Allegiance |
$45.60
|
| Rate for Payer: Monida First Choice Health |
$46.56
|
| Rate for Payer: Monida Montana Health Co-op |
$45.60
|
| Rate for Payer: Monida PacificSource |
$45.60
|
|
|
FENTANYL PATCH [25 MCG/HR]
|
Facility
|
OP
|
$48.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
3000177
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$33.60 |
| Max. Negotiated Rate |
$48.00 |
| Rate for Payer: Aetna Commercial |
$45.60
|
| Rate for Payer: Aetna Medicare |
$43.20
|
| Rate for Payer: BCBS MT CHIP |
$43.20
|
| Rate for Payer: BCBS MT Closed Plan Network |
$45.60
|
| Rate for Payer: BCBS MT HealthLink |
$43.20
|
| Rate for Payer: BCBS MT Medicare |
$43.20
|
| Rate for Payer: BCBS MT POS |
$45.60
|
| Rate for Payer: BCBS MT Traditional |
$48.00
|
| Rate for Payer: Cash Price |
$43.20
|
| Rate for Payer: Cigna Commercial |
$45.60
|
| Rate for Payer: Cigna Medicare |
$43.20
|
| Rate for Payer: Medicaid All Medicaid |
$44.16
|
| Rate for Payer: Medicare All Medicare |
$33.60
|
| Rate for Payer: Monida Allegiance |
$45.60
|
| Rate for Payer: Monida First Choice Health |
$46.56
|
| Rate for Payer: Monida Montana Health Co-op |
$45.60
|
| Rate for Payer: Monida PacificSource |
$45.60
|
|
|
FERRITIN (004598)
|
Facility
|
OP
|
$58.00
|
|
|
Service Code
|
HCPCS 82728
|
| Hospital Charge Code |
4082728
|
|
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
|
|
|
FERRITIN (004598)
|
Facility
|
IP
|
$58.00
|
|
|
Service Code
|
HCPCS 82728
|
| Hospital Charge Code |
4082728
|
|
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
|
|
|
FERRITIN ASSAY
|
Facility
|
IP
|
$144.00
|
|
| Hospital Charge Code |
90197104
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$100.80 |
| Max. Negotiated Rate |
$144.00 |
| Rate for Payer: Aetna Commercial |
$136.80
|
| Rate for Payer: Aetna Medicare |
$129.60
|
| Rate for Payer: BCBS MT CHIP |
$129.60
|
| Rate for Payer: BCBS MT Closed Plan Network |
$136.80
|
| Rate for Payer: BCBS MT HealthLink |
$129.60
|
| Rate for Payer: BCBS MT Medicare |
$129.60
|
| Rate for Payer: BCBS MT POS |
$136.80
|
| Rate for Payer: BCBS MT Traditional |
$144.00
|
| Rate for Payer: Cash Price |
$129.60
|
| Rate for Payer: Cigna Commercial |
$136.80
|
| Rate for Payer: Cigna Medicare |
$129.60
|
| Rate for Payer: Medicaid All Medicaid |
$132.48
|
| Rate for Payer: Medicare All Medicare |
$100.80
|
| Rate for Payer: Monida Allegiance |
$136.80
|
| Rate for Payer: Monida First Choice Health |
$139.68
|
| Rate for Payer: Monida Montana Health Co-op |
$136.80
|
| Rate for Payer: Monida PacificSource |
$136.80
|
|
|
FERRITIN ASSAY
|
Facility
|
OP
|
$144.00
|
|
| Hospital Charge Code |
90197104
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$100.80 |
| Max. Negotiated Rate |
$144.00 |
| Rate for Payer: Aetna Commercial |
$136.80
|
| Rate for Payer: Aetna Medicare |
$129.60
|
| Rate for Payer: BCBS MT CHIP |
$129.60
|
| Rate for Payer: BCBS MT Closed Plan Network |
$136.80
|
| Rate for Payer: BCBS MT HealthLink |
$129.60
|
| Rate for Payer: BCBS MT Medicare |
$129.60
|
| Rate for Payer: BCBS MT POS |
$136.80
|
| Rate for Payer: BCBS MT Traditional |
$144.00
|
| Rate for Payer: Cash Price |
$129.60
|
| Rate for Payer: Cigna Commercial |
$136.80
|
| Rate for Payer: Cigna Medicare |
$129.60
|
| Rate for Payer: Medicaid All Medicaid |
$132.48
|
| Rate for Payer: Medicare All Medicare |
$100.80
|
| Rate for Payer: Monida Allegiance |
$136.80
|
| Rate for Payer: Monida First Choice Health |
$139.68
|
| Rate for Payer: Monida Montana Health Co-op |
$136.80
|
| Rate for Payer: Monida PacificSource |
$136.80
|
|
|
FERROUS SULFATE TAB [325 MG]
|
Facility
|
OP
|
$8.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
3000178
|
|
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
|
|
