|
AMBULANCE GROUND MILEAGE
|
Facility
|
IP
|
$24.00
|
|
|
Service Code
|
HCPCS A0425 QN
|
| Hospital Charge Code |
600425
|
|
Hospital Revenue Code
|
540
|
| 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
|
|
|
AMBULANCE GROUND MILEAGE
|
Facility
|
OP
|
$24.00
|
|
|
Service Code
|
HCPCS A0425 QN
|
| Hospital Charge Code |
600425
|
|
Hospital Revenue Code
|
540
|
| 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
|
|
|
AMBULANCE INTRAOSSEOUS ACCESS
|
Facility
|
IP
|
$223.00
|
|
|
Service Code
|
HCPCS A0999 QN
|
| Hospital Charge Code |
610999
|
|
Hospital Revenue Code
|
540
|
| Min. Negotiated Rate |
$156.10 |
| Max. Negotiated Rate |
$223.00 |
| Rate for Payer: Aetna Commercial |
$211.85
|
| Rate for Payer: Aetna Medicare |
$200.70
|
| Rate for Payer: BCBS MT CHIP |
$200.70
|
| Rate for Payer: BCBS MT Closed Plan Network |
$211.85
|
| Rate for Payer: BCBS MT HealthLink |
$200.70
|
| Rate for Payer: BCBS MT Medicare |
$200.70
|
| Rate for Payer: BCBS MT POS |
$211.85
|
| Rate for Payer: BCBS MT Traditional |
$223.00
|
| Rate for Payer: Cash Price |
$200.70
|
| Rate for Payer: Cigna Commercial |
$211.85
|
| Rate for Payer: Cigna Medicare |
$200.70
|
| Rate for Payer: Medicaid All Medicaid |
$205.16
|
| Rate for Payer: Medicare All Medicare |
$156.10
|
| Rate for Payer: Monida Allegiance |
$211.85
|
| Rate for Payer: Monida First Choice Health |
$216.31
|
| Rate for Payer: Monida Montana Health Co-op |
$211.85
|
| Rate for Payer: Monida PacificSource |
$211.85
|
|
|
AMBULANCE INTRAOSSEOUS ACCESS
|
Facility
|
OP
|
$223.00
|
|
|
Service Code
|
HCPCS A0999 QN
|
| Hospital Charge Code |
610999
|
|
Hospital Revenue Code
|
540
|
| Min. Negotiated Rate |
$156.10 |
| Max. Negotiated Rate |
$223.00 |
| Rate for Payer: Aetna Commercial |
$211.85
|
| Rate for Payer: Aetna Medicare |
$200.70
|
| Rate for Payer: BCBS MT CHIP |
$200.70
|
| Rate for Payer: BCBS MT Closed Plan Network |
$211.85
|
| Rate for Payer: BCBS MT HealthLink |
$200.70
|
| Rate for Payer: BCBS MT Medicare |
$200.70
|
| Rate for Payer: BCBS MT POS |
$211.85
|
| Rate for Payer: BCBS MT Traditional |
$223.00
|
| Rate for Payer: Cash Price |
$200.70
|
| Rate for Payer: Cigna Commercial |
$211.85
|
| Rate for Payer: Cigna Medicare |
$200.70
|
| Rate for Payer: Medicaid All Medicaid |
$205.16
|
| Rate for Payer: Medicare All Medicare |
$156.10
|
| Rate for Payer: Monida Allegiance |
$211.85
|
| Rate for Payer: Monida First Choice Health |
$216.31
|
| Rate for Payer: Monida Montana Health Co-op |
$211.85
|
| Rate for Payer: Monida PacificSource |
$211.85
|
|
|
AMBULANCE IV SUPPLIES
|
Facility
|
IP
|
$45.00
|
|
|
Service Code
|
HCPCS A0394 QN
|
| Hospital Charge Code |
600394
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$31.50 |
| Max. Negotiated Rate |
$45.00 |
| Rate for Payer: Aetna Commercial |
$42.75
|
| Rate for Payer: Aetna Medicare |
$40.50
|
| Rate for Payer: BCBS MT CHIP |
$40.50
|
| Rate for Payer: BCBS MT Closed Plan Network |
$42.75
|
| Rate for Payer: BCBS MT HealthLink |
$40.50
|
| Rate for Payer: BCBS MT Medicare |
$40.50
|
| Rate for Payer: BCBS MT POS |
$42.75
|
| Rate for Payer: BCBS MT Traditional |
$45.00
|
| Rate for Payer: Cash Price |
$40.50
|
| Rate for Payer: Cigna Commercial |
$42.75
|
| Rate for Payer: Cigna Medicare |
$40.50
|
| Rate for Payer: Medicaid All Medicaid |
$41.40
|
| Rate for Payer: Medicare All Medicare |
$31.50
|
| Rate for Payer: Monida Allegiance |
$42.75
|
| Rate for Payer: Monida First Choice Health |
$43.65
|
| Rate for Payer: Monida Montana Health Co-op |
$42.75
|
| Rate for Payer: Monida PacificSource |
$42.75
|
|
|
AMBULANCE IV SUPPLIES
|
Facility
|
OP
|
$45.00
|
|
|
Service Code
|
HCPCS A0394 QN
|
| Hospital Charge Code |
600394
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$31.50 |
| Max. Negotiated Rate |
$45.00 |
| Rate for Payer: Aetna Commercial |
$42.75
|
| Rate for Payer: Aetna Medicare |
$40.50
|
| Rate for Payer: BCBS MT CHIP |
$40.50
|
| Rate for Payer: BCBS MT Closed Plan Network |
$42.75
|
| Rate for Payer: BCBS MT HealthLink |
$40.50
|
| Rate for Payer: BCBS MT Medicare |
$40.50
|
| Rate for Payer: BCBS MT POS |
$42.75
|
| Rate for Payer: BCBS MT Traditional |
$45.00
|
| Rate for Payer: Cash Price |
$40.50
|
| Rate for Payer: Cigna Commercial |
$42.75
|
| Rate for Payer: Cigna Medicare |
$40.50
|
| Rate for Payer: Medicaid All Medicaid |
$41.40
|
| Rate for Payer: Medicare All Medicare |
$31.50
|
| Rate for Payer: Monida Allegiance |
$42.75
|
| Rate for Payer: Monida First Choice Health |
$43.65
|
| Rate for Payer: Monida Montana Health Co-op |
$42.75
|
| Rate for Payer: Monida PacificSource |
$42.75
|
|
|
AMBULANCE O2 LIFE SAVING PER 1/2 HR
|
Facility
|
IP
|
$56.00
|
|
|
Service Code
|
HCPCS A0422 QN
|
| Hospital Charge Code |
600422
|
|
Hospital Revenue Code
|
420
|
| 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
|
|
|
AMBULANCE O2 LIFE SAVING PER 1/2 HR
|
Facility
|
OP
|
$56.00
|
|
|
Service Code
|
HCPCS A0422 QN
|
| Hospital Charge Code |
600422
|
|
Hospital Revenue Code
|
420
|
| 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
|
|
|
AMBULANCE RESPONSE & TREAT NO TRANSPORT
|
Facility
|
IP
|
$167.00
|
|
|
Service Code
|
HCPCS A0433 QN
|
| Hospital Charge Code |
600998
|
|
Hospital Revenue Code
|
540
|
| Min. Negotiated Rate |
$116.90 |
| Max. Negotiated Rate |
$167.00 |
| Rate for Payer: Aetna Commercial |
$158.65
|
| Rate for Payer: Aetna Medicare |
$150.30
|
| Rate for Payer: BCBS MT CHIP |
$150.30
|
| Rate for Payer: BCBS MT Closed Plan Network |
$158.65
|
| Rate for Payer: BCBS MT HealthLink |
$150.30
|
| Rate for Payer: BCBS MT Medicare |
$150.30
|
| Rate for Payer: BCBS MT POS |
$158.65
|
| Rate for Payer: BCBS MT Traditional |
$167.00
|
| Rate for Payer: Cash Price |
$150.30
|
| Rate for Payer: Cigna Commercial |
$158.65
|
| Rate for Payer: Cigna Medicare |
$150.30
|
| Rate for Payer: Medicaid All Medicaid |
$153.64
|
| Rate for Payer: Medicare All Medicare |
$116.90
|
| Rate for Payer: Monida Allegiance |
$158.65
|
| Rate for Payer: Monida First Choice Health |
$161.99
|
| Rate for Payer: Monida Montana Health Co-op |
$158.65
|
| Rate for Payer: Monida PacificSource |
$158.65
|
|
|
AMBULANCE RESPONSE & TREAT NO TRANSPORT
|
Facility
|
OP
|
$167.00
|
|
|
Service Code
|
HCPCS A0433 QN
|
| Hospital Charge Code |
600998
|
|
Hospital Revenue Code
|
540
|
| Min. Negotiated Rate |
$116.90 |
| Max. Negotiated Rate |
$167.00 |
| Rate for Payer: Aetna Commercial |
$158.65
|
| Rate for Payer: Aetna Medicare |
$150.30
|
| Rate for Payer: BCBS MT CHIP |
$150.30
|
| Rate for Payer: BCBS MT Closed Plan Network |
$158.65
|
| Rate for Payer: BCBS MT HealthLink |
$150.30
|
| Rate for Payer: BCBS MT Medicare |
$150.30
|
| Rate for Payer: BCBS MT POS |
$158.65
|
| Rate for Payer: BCBS MT Traditional |
$167.00
|
| Rate for Payer: Cash Price |
$150.30
|
| Rate for Payer: Cigna Commercial |
$158.65
|
| Rate for Payer: Cigna Medicare |
$150.30
|
| Rate for Payer: Medicaid All Medicaid |
$153.64
|
| Rate for Payer: Medicare All Medicare |
$116.90
|
| Rate for Payer: Monida Allegiance |
$158.65
|
| Rate for Payer: Monida First Choice Health |
$161.99
|
| Rate for Payer: Monida Montana Health Co-op |
$158.65
|
| Rate for Payer: Monida PacificSource |
$158.65
|
|
|
AMIODARONE INJ [150 MG/3 ML]
|
Facility
|
OP
|
$8.00
|
|
|
Service Code
|
HCPCS J0282
|
| Hospital Charge Code |
3000022
|
|
Hospital Revenue Code
|
259
|
| 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
|
|
|
AMIODARONE INJ [150 MG/3 ML]
|
Facility
|
IP
|
$8.00
|
|
|
Service Code
|
HCPCS J0282
|
| Hospital Charge Code |
3000022
|
|
Hospital Revenue Code
|
259
|
| 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
|
|
|
AMIODARONE TAB [200 MG]
|
Facility
|
IP
|
$8.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
3000023
|
|
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
|
|
|
AMIODARONE TAB [200 MG]
|
Facility
|
OP
|
$8.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
3000023
|
|
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
|
|
|
AMITRIPTYLINE TAB [25 MG]
|
Facility
|
OP
|
$8.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
3000024
|
|
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
|
|
|
AMITRIPTYLINE TAB [25 MG]
|
Facility
|
IP
|
$8.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
3000024
|
|
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
|
|
|
AMLODIPINE TAB [10 MG] NF
|
Facility
|
IP
|
$8.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
3007434
|
|
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
|
|
|
AMLODIPINE TAB [10 MG] NF
|
Facility
|
OP
|
$8.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
3007434
|
|
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
|
|
|
AMLODIPINE TAB [2.5 MG] NF
|
Facility
|
OP
|
$8.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
3007509
|
|
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
|
|
|
AMLODIPINE TAB [2.5 MG] NF
|
Facility
|
IP
|
$8.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
3007509
|
|
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
|
|
|
AMLODIPINE TAB [5 MG]
|
Facility
|
IP
|
$8.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
3000025
|
|
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
|
|
|
AMLODIPINE TAB [5 MG]
|
Facility
|
OP
|
$8.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
3000025
|
|
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
|
|
|
AMMONIA (007054)
|
Facility
|
OP
|
$69.00
|
|
|
Service Code
|
HCPCS 82140
|
| Hospital Charge Code |
4082140
|
|
Hospital Revenue Code
|
301
|
| 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
|
|
|
AMMONIA (007054)
|
Facility
|
IP
|
$69.00
|
|
|
Service Code
|
HCPCS 82140
|
| Hospital Charge Code |
4082140
|
|
Hospital Revenue Code
|
301
|
| 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
|
|
|
AMMONIA RVMC
|
Facility
|
IP
|
$135.00
|
|
|
Service Code
|
HCPCS 82140
|
| Hospital Charge Code |
4087915
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$94.50 |
| Max. Negotiated Rate |
$135.00 |
| Rate for Payer: Aetna Commercial |
$128.25
|
| Rate for Payer: Aetna Medicare |
$121.50
|
| Rate for Payer: BCBS MT CHIP |
$121.50
|
| Rate for Payer: BCBS MT Closed Plan Network |
$128.25
|
| Rate for Payer: BCBS MT HealthLink |
$121.50
|
| Rate for Payer: BCBS MT Medicare |
$121.50
|
| Rate for Payer: BCBS MT POS |
$128.25
|
| Rate for Payer: BCBS MT Traditional |
$135.00
|
| Rate for Payer: Cash Price |
$121.50
|
| Rate for Payer: Cigna Commercial |
$128.25
|
| Rate for Payer: Cigna Medicare |
$121.50
|
| Rate for Payer: Medicaid All Medicaid |
$124.20
|
| Rate for Payer: Medicare All Medicare |
$94.50
|
| Rate for Payer: Monida Allegiance |
$128.25
|
| Rate for Payer: Monida First Choice Health |
$130.95
|
| Rate for Payer: Monida Montana Health Co-op |
$128.25
|
| Rate for Payer: Monida PacificSource |
$128.25
|
|
