|
INTREPID INITIAL EVAL/DISCHARGE
|
Facility
|
IP
|
$176.00
|
|
|
Service Code
|
HCPCS G0151
|
| Hospital Charge Code |
611001
|
|
Hospital Revenue Code
|
421
|
| Min. Negotiated Rate |
$123.20 |
| Max. Negotiated Rate |
$176.00 |
| Rate for Payer: Aetna Commercial |
$167.20
|
| Rate for Payer: Aetna Medicare |
$158.40
|
| Rate for Payer: BCBS MT CHIP |
$158.40
|
| Rate for Payer: BCBS MT Closed Plan Network |
$167.20
|
| Rate for Payer: BCBS MT HealthLink |
$158.40
|
| Rate for Payer: BCBS MT Medicare |
$158.40
|
| Rate for Payer: BCBS MT POS |
$167.20
|
| Rate for Payer: BCBS MT Traditional |
$176.00
|
| Rate for Payer: Cash Price |
$158.40
|
| Rate for Payer: Cigna Commercial |
$167.20
|
| Rate for Payer: Cigna Medicare |
$158.40
|
| Rate for Payer: Medicaid All Medicaid |
$161.92
|
| Rate for Payer: Medicare All Medicare |
$123.20
|
| Rate for Payer: Monida Allegiance |
$167.20
|
| Rate for Payer: Monida First Choice Health |
$170.72
|
| Rate for Payer: Monida Montana Health Co-op |
$167.20
|
| Rate for Payer: Monida PacificSource |
$167.20
|
|
|
INTREPID ORIENTATION OF STAFF
|
Facility
|
IP
|
$45.00
|
|
| Hospital Charge Code |
611002
|
|
Hospital Revenue Code
|
421
|
| 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
|
|
|
INTREPID ORIENTATION OF STAFF
|
Facility
|
OP
|
$45.00
|
|
| Hospital Charge Code |
611002
|
|
Hospital Revenue Code
|
421
|
| 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
|
|
|
INTREPID TRAVEL TIME/HR
|
Facility
|
OP
|
$64.00
|
|
| Hospital Charge Code |
611006
|
|
Hospital Revenue Code
|
429
|
| Min. Negotiated Rate |
$44.80 |
| Max. Negotiated Rate |
$64.00 |
| Rate for Payer: Aetna Commercial |
$60.80
|
| Rate for Payer: Aetna Medicare |
$57.60
|
| Rate for Payer: BCBS MT CHIP |
$57.60
|
| Rate for Payer: BCBS MT Closed Plan Network |
$60.80
|
| Rate for Payer: BCBS MT HealthLink |
$57.60
|
| Rate for Payer: BCBS MT Medicare |
$57.60
|
| Rate for Payer: BCBS MT POS |
$60.80
|
| Rate for Payer: BCBS MT Traditional |
$64.00
|
| Rate for Payer: Cash Price |
$57.60
|
| Rate for Payer: Cigna Commercial |
$60.80
|
| Rate for Payer: Cigna Medicare |
$57.60
|
| Rate for Payer: Medicaid All Medicaid |
$58.88
|
| Rate for Payer: Medicare All Medicare |
$44.80
|
| Rate for Payer: Monida Allegiance |
$60.80
|
| Rate for Payer: Monida First Choice Health |
$62.08
|
| Rate for Payer: Monida Montana Health Co-op |
$60.80
|
| Rate for Payer: Monida PacificSource |
$60.80
|
|
|
INTREPID TRAVEL TIME/HR
|
Facility
|
IP
|
$64.00
|
|
| Hospital Charge Code |
611006
|
|
Hospital Revenue Code
|
429
|
| Min. Negotiated Rate |
$44.80 |
| Max. Negotiated Rate |
$64.00 |
| Rate for Payer: Aetna Commercial |
$60.80
|
| Rate for Payer: Aetna Medicare |
$57.60
|
| Rate for Payer: BCBS MT CHIP |
$57.60
|
| Rate for Payer: BCBS MT Closed Plan Network |
$60.80
|
| Rate for Payer: BCBS MT HealthLink |
$57.60
|
| Rate for Payer: BCBS MT Medicare |
$57.60
|
| Rate for Payer: BCBS MT POS |
$60.80
|
| Rate for Payer: BCBS MT Traditional |
$64.00
|
| Rate for Payer: Cash Price |
$57.60
|
| Rate for Payer: Cigna Commercial |
$60.80
|
| Rate for Payer: Cigna Medicare |
$57.60
|
| Rate for Payer: Medicaid All Medicaid |
$58.88
|
| Rate for Payer: Medicare All Medicare |
$44.80
|
| Rate for Payer: Monida Allegiance |
$60.80
|
| Rate for Payer: Monida First Choice Health |
$62.08
|
| Rate for Payer: Monida Montana Health Co-op |
$60.80
|
| Rate for Payer: Monida PacificSource |
$60.80
|
|
|
INTREPID VISIT
|
Facility
|
OP
|
$89.00
|
|
|
Service Code
|
HCPCS G0151
|
| Hospital Charge Code |
611005
|
|
Hospital Revenue Code
|
421
|
| 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
|
|
|
INTREPID VISIT
|
Facility
|
IP
|
$89.00
|
|
|
Service Code
|
HCPCS G0151
|
| Hospital Charge Code |
611005
|
|
Hospital Revenue Code
|
421
|
| 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
|
|
|
INVALID RING
|
Facility
|
OP
|
$9.00
|
|
| Hospital Charge Code |
2830195
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$6.30 |
| Max. Negotiated Rate |
$9.00 |
| Rate for Payer: Aetna Commercial |
$8.55
|
| Rate for Payer: Aetna Medicare |
$8.10
|
| Rate for Payer: BCBS MT CHIP |
$8.10
|
| Rate for Payer: BCBS MT Closed Plan Network |
$8.55
|
| Rate for Payer: BCBS MT HealthLink |
$8.10
|
| Rate for Payer: BCBS MT Medicare |
$8.10
|
| Rate for Payer: BCBS MT POS |
$8.55
|
| Rate for Payer: BCBS MT Traditional |
$9.00
|
| Rate for Payer: Cash Price |
$8.10
|
| Rate for Payer: Cigna Commercial |
$8.55
|
| Rate for Payer: Cigna Medicare |
$8.10
|
| Rate for Payer: Medicaid All Medicaid |
$8.28
|
| Rate for Payer: Medicare All Medicare |
$6.30
|
| Rate for Payer: Monida Allegiance |
$8.55
|
| Rate for Payer: Monida First Choice Health |
$8.73
|
| Rate for Payer: Monida Montana Health Co-op |
$8.55
|
| Rate for Payer: Monida PacificSource |
$8.55
|
|
|
INVALID RING
|
Facility
|
IP
|
$9.00
|
|
| Hospital Charge Code |
2830195
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$6.30 |
| Max. Negotiated Rate |
$9.00 |
| Rate for Payer: Aetna Commercial |
$8.55
|
| Rate for Payer: Aetna Medicare |
$8.10
|
| Rate for Payer: BCBS MT CHIP |
$8.10
|
| Rate for Payer: BCBS MT Closed Plan Network |
$8.55
|
| Rate for Payer: BCBS MT HealthLink |
$8.10
|
| Rate for Payer: BCBS MT Medicare |
$8.10
|
| Rate for Payer: BCBS MT POS |
$8.55
|
| Rate for Payer: BCBS MT Traditional |
$9.00
|
| Rate for Payer: Cash Price |
$8.10
|
| Rate for Payer: Cigna Commercial |
$8.55
|
| Rate for Payer: Cigna Medicare |
$8.10
|
| Rate for Payer: Medicaid All Medicaid |
$8.28
|
| Rate for Payer: Medicare All Medicare |
$6.30
|
| Rate for Payer: Monida Allegiance |
$8.55
|
| Rate for Payer: Monida First Choice Health |
$8.73
|
| Rate for Payer: Monida Montana Health Co-op |
$8.55
|
| Rate for Payer: Monida PacificSource |
$8.55
|
|
|
IODOFORM PACKING 1/4 "
|
Facility
|
OP
|
$4.00
|
|
| Hospital Charge Code |
80030179
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$2.80 |
| Max. Negotiated Rate |
$4.00 |
| Rate for Payer: Aetna Commercial |
$3.80
|
| Rate for Payer: Aetna Medicare |
$3.60
|
| Rate for Payer: BCBS MT CHIP |
$3.60
|
| Rate for Payer: BCBS MT Closed Plan Network |
$3.80
|
| Rate for Payer: BCBS MT HealthLink |
$3.60
|
| Rate for Payer: BCBS MT Medicare |
$3.60
|
| Rate for Payer: BCBS MT POS |
$3.80
|
| Rate for Payer: BCBS MT Traditional |
$4.00
|
| Rate for Payer: Cash Price |
$3.60
|
| Rate for Payer: Cigna Commercial |
$3.80
|
| Rate for Payer: Cigna Medicare |
$3.60
|
| Rate for Payer: Medicaid All Medicaid |
$3.68
|
| Rate for Payer: Medicare All Medicare |
$2.80
|
| Rate for Payer: Monida Allegiance |
$3.80
|
| Rate for Payer: Monida First Choice Health |
$3.88
|
| Rate for Payer: Monida Montana Health Co-op |
$3.80
|
| Rate for Payer: Monida PacificSource |
$3.80
|
|
|
IODOFORM PACKING 1/4 "
|
Facility
|
IP
|
$4.00
|
|
| Hospital Charge Code |
80030179
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$2.80 |
| Max. Negotiated Rate |
$4.00 |
| Rate for Payer: Aetna Commercial |
$3.80
|
| Rate for Payer: Aetna Medicare |
$3.60
|
| Rate for Payer: BCBS MT CHIP |
$3.60
|
| Rate for Payer: BCBS MT Closed Plan Network |
$3.80
|
| Rate for Payer: BCBS MT HealthLink |
$3.60
|
| Rate for Payer: BCBS MT Medicare |
$3.60
|
| Rate for Payer: BCBS MT POS |
$3.80
|
| Rate for Payer: BCBS MT Traditional |
$4.00
|
| Rate for Payer: Cash Price |
$3.60
|
| Rate for Payer: Cigna Commercial |
$3.80
|
| Rate for Payer: Cigna Medicare |
$3.60
|
| Rate for Payer: Medicaid All Medicaid |
$3.68
|
| Rate for Payer: Medicare All Medicare |
$2.80
|
| Rate for Payer: Monida Allegiance |
$3.80
|
| Rate for Payer: Monida First Choice Health |
$3.88
|
| Rate for Payer: Monida Montana Health Co-op |
$3.80
|
| Rate for Payer: Monida PacificSource |
$3.80
|
|
|
IPRATROP/ALBUTEROL MDI [20/100MCG] NF
|
Facility
|
OP
|
$999.00
|
|
|
Service Code
|
HCPCS J7620
|
| Hospital Charge Code |
3000237
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$699.30 |
| Max. Negotiated Rate |
$999.00 |
| Rate for Payer: Aetna Commercial |
$949.05
|
| Rate for Payer: Aetna Medicare |
$899.10
|
| Rate for Payer: BCBS MT CHIP |
$899.10
|
| Rate for Payer: BCBS MT Closed Plan Network |
$949.05
|
| Rate for Payer: BCBS MT HealthLink |
$899.10
|
| Rate for Payer: BCBS MT Medicare |
$899.10
|
| Rate for Payer: BCBS MT POS |
$949.05
|
| Rate for Payer: BCBS MT Traditional |
$999.00
|
| Rate for Payer: Cash Price |
$899.10
|
| Rate for Payer: Cigna Commercial |
$949.05
|
| Rate for Payer: Cigna Medicare |
$899.10
|
| Rate for Payer: Medicaid All Medicaid |
$919.08
|
| Rate for Payer: Medicare All Medicare |
$699.30
|
| Rate for Payer: Monida Allegiance |
$949.05
|
| Rate for Payer: Monida First Choice Health |
$969.03
|
| Rate for Payer: Monida Montana Health Co-op |
$949.05
|
| Rate for Payer: Monida PacificSource |
$949.05
|
|
|
IPRATROP/ALBUTEROL MDI [20/100MCG] NF
|
Facility
|
IP
|
$999.00
|
|
|
Service Code
|
HCPCS J7620
|
| Hospital Charge Code |
3000237
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$699.30 |
| Max. Negotiated Rate |
$999.00 |
| Rate for Payer: Aetna Commercial |
$949.05
|
| Rate for Payer: Aetna Medicare |
$899.10
|
| Rate for Payer: BCBS MT CHIP |
$899.10
|
| Rate for Payer: BCBS MT Closed Plan Network |
$949.05
|
| Rate for Payer: BCBS MT HealthLink |
$899.10
|
| Rate for Payer: BCBS MT Medicare |
$899.10
|
| Rate for Payer: BCBS MT POS |
$949.05
|
| Rate for Payer: BCBS MT Traditional |
$999.00
|
| Rate for Payer: Cash Price |
$899.10
|
| Rate for Payer: Cigna Commercial |
$949.05
|
| Rate for Payer: Cigna Medicare |
$899.10
|
| Rate for Payer: Medicaid All Medicaid |
$919.08
|
| Rate for Payer: Medicare All Medicare |
$699.30
|
| Rate for Payer: Monida Allegiance |
$949.05
|
| Rate for Payer: Monida First Choice Health |
$969.03
|
| Rate for Payer: Monida Montana Health Co-op |
$949.05
|
| Rate for Payer: Monida PacificSource |
$949.05
|
|
|
IPRATROPIUM NEB SOLN 0.02%
|
Facility
|
IP
|
$8.00
|
|
|
Service Code
|
HCPCS J7644
|
| Hospital Charge Code |
3000238
|
|
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
|
|
|
IPRATROPIUM NEB SOLN 0.02%
|
Facility
|
OP
|
$8.00
|
|
|
Service Code
|
HCPCS J7644
|
| Hospital Charge Code |
3000238
|
|
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
|
|
|
IRON SUCROSE INJ 20MG/ML (10ML VIAL)
|
Facility
|
OP
|
$443.60
|
|
|
Service Code
|
NDC 00517231005
|
| Hospital Charge Code |
3007258
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$310.52 |
| Max. Negotiated Rate |
$443.60 |
| Rate for Payer: Aetna Commercial |
$421.42
|
| Rate for Payer: Aetna Medicare |
$399.24
|
| Rate for Payer: BCBS MT CHIP |
$399.24
|
| Rate for Payer: BCBS MT Closed Plan Network |
$421.42
|
| Rate for Payer: BCBS MT HealthLink |
$399.24
|
| Rate for Payer: BCBS MT Medicare |
$399.24
|
| Rate for Payer: BCBS MT POS |
$421.42
|
| Rate for Payer: BCBS MT Traditional |
$443.60
|
| Rate for Payer: Cash Price |
$399.24
|
| Rate for Payer: Cigna Commercial |
$421.42
|
| Rate for Payer: Cigna Medicare |
$399.24
|
| Rate for Payer: Medicaid All Medicaid |
$408.11
|
| Rate for Payer: Medicare All Medicare |
$310.52
|
| Rate for Payer: Monida Allegiance |
$421.42
|
| Rate for Payer: Monida First Choice Health |
$430.29
|
| Rate for Payer: Monida Montana Health Co-op |
$421.42
|
| Rate for Payer: Monida PacificSource |
$421.42
|
|
|
IRON SUCROSE INJ 20MG/ML (10ML VIAL)
|
Facility
|
IP
|
$443.60
|
|
|
Service Code
|
NDC 00517231005
|
| Hospital Charge Code |
3007258
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$310.52 |
| Max. Negotiated Rate |
$443.60 |
| Rate for Payer: Aetna Commercial |
$421.42
|
| Rate for Payer: Aetna Medicare |
$399.24
|
| Rate for Payer: BCBS MT CHIP |
$399.24
|
| Rate for Payer: BCBS MT Closed Plan Network |
$421.42
|
| Rate for Payer: BCBS MT HealthLink |
$399.24
|
| Rate for Payer: BCBS MT Medicare |
$399.24
|
| Rate for Payer: BCBS MT POS |
$421.42
|
| Rate for Payer: BCBS MT Traditional |
$443.60
|
| Rate for Payer: Cash Price |
$399.24
|
| Rate for Payer: Cigna Commercial |
$421.42
|
| Rate for Payer: Cigna Medicare |
$399.24
|
| Rate for Payer: Medicaid All Medicaid |
$408.11
|
| Rate for Payer: Medicare All Medicare |
$310.52
|
| Rate for Payer: Monida Allegiance |
$421.42
|
| Rate for Payer: Monida First Choice Health |
$430.29
|
| Rate for Payer: Monida Montana Health Co-op |
$421.42
|
| Rate for Payer: Monida PacificSource |
$421.42
|
|
|
.IRON, TOTAL
|
Facility
|
IP
|
$9.00
|
|
|
Service Code
|
HCPCS 83540
|
| Hospital Charge Code |
4035401
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$6.30 |
| Max. Negotiated Rate |
$9.00 |
| Rate for Payer: Aetna Commercial |
$8.55
|
| Rate for Payer: Aetna Medicare |
$8.10
|
| Rate for Payer: BCBS MT CHIP |
$8.10
|
| Rate for Payer: BCBS MT Closed Plan Network |
$8.55
|
| Rate for Payer: BCBS MT HealthLink |
$8.10
|
| Rate for Payer: BCBS MT Medicare |
$8.10
|
| Rate for Payer: BCBS MT POS |
$8.55
|
| Rate for Payer: BCBS MT Traditional |
$9.00
|
| Rate for Payer: Cash Price |
$8.10
|
| Rate for Payer: Cigna Commercial |
$8.55
|
| Rate for Payer: Cigna Medicare |
$8.10
|
| Rate for Payer: Medicaid All Medicaid |
$8.28
|
| Rate for Payer: Medicare All Medicare |
$6.30
|
| Rate for Payer: Monida Allegiance |
$8.55
|
| Rate for Payer: Monida First Choice Health |
$8.73
|
| Rate for Payer: Monida Montana Health Co-op |
$8.55
|
| Rate for Payer: Monida PacificSource |
$8.55
|
|
|
.IRON, TOTAL
|
Facility
|
OP
|
$9.00
|
|
|
Service Code
|
HCPCS 83540
|
| Hospital Charge Code |
4035401
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$6.30 |
| Max. Negotiated Rate |
$9.00 |
| Rate for Payer: Aetna Commercial |
$8.55
|
| Rate for Payer: Aetna Medicare |
$8.10
|
| Rate for Payer: BCBS MT CHIP |
$8.10
|
| Rate for Payer: BCBS MT Closed Plan Network |
$8.55
|
| Rate for Payer: BCBS MT HealthLink |
$8.10
|
| Rate for Payer: BCBS MT Medicare |
$8.10
|
| Rate for Payer: BCBS MT POS |
$8.55
|
| Rate for Payer: BCBS MT Traditional |
$9.00
|
| Rate for Payer: Cash Price |
$8.10
|
| Rate for Payer: Cigna Commercial |
$8.55
|
| Rate for Payer: Cigna Medicare |
$8.10
|
| Rate for Payer: Medicaid All Medicaid |
$8.28
|
| Rate for Payer: Medicare All Medicare |
$6.30
|
| Rate for Payer: Monida Allegiance |
$8.55
|
| Rate for Payer: Monida First Choice Health |
$8.73
|
| Rate for Payer: Monida Montana Health Co-op |
$8.55
|
| Rate for Payer: Monida PacificSource |
$8.55
|
|
|
IRON, TOTAL (001339)
|
Facility
|
OP
|
$9.00
|
|
|
Service Code
|
HCPCS 83540
|
| Hospital Charge Code |
4083540
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$6.30 |
| Max. Negotiated Rate |
$9.00 |
| Rate for Payer: Aetna Commercial |
$8.55
|
| Rate for Payer: Aetna Medicare |
$8.10
|
| Rate for Payer: BCBS MT CHIP |
$8.10
|
| Rate for Payer: BCBS MT Closed Plan Network |
$8.55
|
| Rate for Payer: BCBS MT HealthLink |
$8.10
|
| Rate for Payer: BCBS MT Medicare |
$8.10
|
| Rate for Payer: BCBS MT POS |
$8.55
|
| Rate for Payer: BCBS MT Traditional |
$9.00
|
| Rate for Payer: Cash Price |
$8.10
|
| Rate for Payer: Cigna Commercial |
$8.55
|
| Rate for Payer: Cigna Medicare |
$8.10
|
| Rate for Payer: Medicaid All Medicaid |
$8.28
|
| Rate for Payer: Medicare All Medicare |
$6.30
|
| Rate for Payer: Monida Allegiance |
$8.55
|
| Rate for Payer: Monida First Choice Health |
$8.73
|
| Rate for Payer: Monida Montana Health Co-op |
$8.55
|
| Rate for Payer: Monida PacificSource |
$8.55
|
|
|
IRON, TOTAL (001339)
|
Facility
|
IP
|
$9.00
|
|
|
Service Code
|
HCPCS 83540
|
| Hospital Charge Code |
4083540
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$6.30 |
| Max. Negotiated Rate |
$9.00 |
| Rate for Payer: Aetna Commercial |
$8.55
|
| Rate for Payer: Aetna Medicare |
$8.10
|
| Rate for Payer: BCBS MT CHIP |
$8.10
|
| Rate for Payer: BCBS MT Closed Plan Network |
$8.55
|
| Rate for Payer: BCBS MT HealthLink |
$8.10
|
| Rate for Payer: BCBS MT Medicare |
$8.10
|
| Rate for Payer: BCBS MT POS |
$8.55
|
| Rate for Payer: BCBS MT Traditional |
$9.00
|
| Rate for Payer: Cash Price |
$8.10
|
| Rate for Payer: Cigna Commercial |
$8.55
|
| Rate for Payer: Cigna Medicare |
$8.10
|
| Rate for Payer: Medicaid All Medicaid |
$8.28
|
| Rate for Payer: Medicare All Medicare |
$6.30
|
| Rate for Payer: Monida Allegiance |
$8.55
|
| Rate for Payer: Monida First Choice Health |
$8.73
|
| Rate for Payer: Monida Montana Health Co-op |
$8.55
|
| Rate for Payer: Monida PacificSource |
$8.55
|
|
|
IRRIGATION OF IMPLANTED VENOUS ACCESS TR
|
Facility
|
IP
|
$135.00
|
|
|
Service Code
|
HCPCS 96523
|
| Hospital Charge Code |
1096523
|
|
Hospital Revenue Code
|
761
|
| 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
|
|
|
IRRIGATION OF IMPLANTED VENOUS ACCESS TR
|
Facility
|
OP
|
$135.00
|
|
|
Service Code
|
HCPCS 96523
|
| Hospital Charge Code |
1096523
|
|
Hospital Revenue Code
|
761
|
| 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
|
|
|
ISOSORBIDE DINITRATE TAB [10 MG]
|
Facility
|
IP
|
$8.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
3000239
|
|
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
|
|
|
ISOSORBIDE DINITRATE TAB [10 MG]
|
Facility
|
OP
|
$8.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
3000239
|
|
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
|
|
