|
EXCSION BNIGN LSION + MARG 0.6-1CM(11421
|
Facility
|
IP
|
$586.00
|
|
|
Service Code
|
CPT 11421
|
| Hospital Charge Code |
8011421
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$410.20 |
| Max. Negotiated Rate |
$586.00 |
| Rate for Payer: Aetna Commercial |
$556.70
|
| Rate for Payer: Aetna Medicare |
$527.40
|
| Rate for Payer: BCBS MT CHIP |
$527.40
|
| Rate for Payer: BCBS MT Closed Plan Network |
$556.70
|
| Rate for Payer: BCBS MT HealthLink |
$527.40
|
| Rate for Payer: BCBS MT Medicare |
$527.40
|
| Rate for Payer: BCBS MT POS |
$556.70
|
| Rate for Payer: BCBS MT Traditional |
$586.00
|
| Rate for Payer: Cash Price |
$527.40
|
| Rate for Payer: Cigna Commercial |
$556.70
|
| Rate for Payer: Cigna Medicare |
$527.40
|
| Rate for Payer: Medicaid All Medicaid |
$539.12
|
| Rate for Payer: Medicare All Medicare |
$410.20
|
| Rate for Payer: Monida Allegiance |
$556.70
|
| Rate for Payer: Monida First Choice Health |
$568.42
|
| Rate for Payer: Monida Montana Health Co-op |
$556.70
|
| Rate for Payer: Monida PacificSource |
$556.70
|
|
|
.EXTRACTABLE NUCLEAR AG AB (160014)
|
Facility
|
IP
|
$114.00
|
|
|
Service Code
|
CPT 86235
|
| Hospital Charge Code |
4062350
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$79.80 |
| Max. Negotiated Rate |
$114.00 |
| Rate for Payer: Aetna Commercial |
$108.30
|
| Rate for Payer: Aetna Medicare |
$102.60
|
| Rate for Payer: BCBS MT CHIP |
$102.60
|
| Rate for Payer: BCBS MT Closed Plan Network |
$108.30
|
| Rate for Payer: BCBS MT HealthLink |
$102.60
|
| Rate for Payer: BCBS MT Medicare |
$102.60
|
| Rate for Payer: BCBS MT POS |
$108.30
|
| Rate for Payer: BCBS MT Traditional |
$114.00
|
| Rate for Payer: Cash Price |
$102.60
|
| Rate for Payer: Cigna Commercial |
$108.30
|
| Rate for Payer: Cigna Medicare |
$102.60
|
| Rate for Payer: Medicaid All Medicaid |
$104.88
|
| Rate for Payer: Medicare All Medicare |
$79.80
|
| Rate for Payer: Monida Allegiance |
$108.30
|
| Rate for Payer: Monida First Choice Health |
$110.58
|
| Rate for Payer: Monida Montana Health Co-op |
$108.30
|
| Rate for Payer: Monida PacificSource |
$108.30
|
|
|
.EXTRACTABLE NUCLEAR AG AB (160014)
|
Facility
|
OP
|
$114.00
|
|
|
Service Code
|
CPT 86235
|
| Hospital Charge Code |
4062350
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$79.80 |
| Max. Negotiated Rate |
$114.00 |
| Rate for Payer: Aetna Commercial |
$108.30
|
| Rate for Payer: Aetna Medicare |
$102.60
|
| Rate for Payer: BCBS MT CHIP |
$102.60
|
| Rate for Payer: BCBS MT Closed Plan Network |
$108.30
|
| Rate for Payer: BCBS MT HealthLink |
$102.60
|
| Rate for Payer: BCBS MT Medicare |
$102.60
|
| Rate for Payer: BCBS MT POS |
$108.30
|
| Rate for Payer: BCBS MT Traditional |
$114.00
|
| Rate for Payer: Cash Price |
$102.60
|
| Rate for Payer: Cigna Commercial |
$108.30
|
| Rate for Payer: Cigna Medicare |
$102.60
|
| Rate for Payer: Medicaid All Medicaid |
$104.88
|
| Rate for Payer: Medicare All Medicare |
$79.80
|
| Rate for Payer: Monida Allegiance |
$108.30
|
| Rate for Payer: Monida First Choice Health |
$110.58
|
| Rate for Payer: Monida Montana Health Co-op |
$108.30
|
| Rate for Payer: Monida PacificSource |
$108.30
|
|
|
EXTRACTABLE NUCLEAR ANTIGEN 3
|
Facility
|
IP
|
$96.00
|
|
|
Service Code
|
CPT 86235
|
| Hospital Charge Code |
4088099
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$67.20 |
| Max. Negotiated Rate |
$96.00 |
| Rate for Payer: Aetna Commercial |
$91.20
|
| Rate for Payer: Aetna Medicare |
$86.40
|
| Rate for Payer: BCBS MT CHIP |
$86.40
|
| Rate for Payer: BCBS MT Closed Plan Network |
$91.20
|
| Rate for Payer: BCBS MT HealthLink |
$86.40
|
| Rate for Payer: BCBS MT Medicare |
$86.40
|
| Rate for Payer: BCBS MT POS |
$91.20
|
| Rate for Payer: BCBS MT Traditional |
$96.00
|
| Rate for Payer: Cash Price |
$86.40
|
| Rate for Payer: Cigna Commercial |
$91.20
|
| Rate for Payer: Cigna Medicare |
$86.40
|
| Rate for Payer: Medicaid All Medicaid |
$88.32
|
| Rate for Payer: Medicare All Medicare |
$67.20
|
| Rate for Payer: Monida Allegiance |
$91.20
|
| Rate for Payer: Monida First Choice Health |
$93.12
|
| Rate for Payer: Monida Montana Health Co-op |
$91.20
|
| Rate for Payer: Monida PacificSource |
$91.20
|
|
|
EXTRACTABLE NUCLEAR ANTIGEN 3
|
Facility
|
OP
|
$96.00
|
|
|
Service Code
|
CPT 86235
|
| Hospital Charge Code |
4088099
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$67.20 |
| Max. Negotiated Rate |
$96.00 |
| Rate for Payer: Aetna Commercial |
$91.20
|
| Rate for Payer: Aetna Medicare |
$86.40
|
| Rate for Payer: BCBS MT CHIP |
$86.40
|
| Rate for Payer: BCBS MT Closed Plan Network |
$91.20
|
| Rate for Payer: BCBS MT HealthLink |
$86.40
|
| Rate for Payer: BCBS MT Medicare |
$86.40
|
| Rate for Payer: BCBS MT POS |
$91.20
|
| Rate for Payer: BCBS MT Traditional |
$96.00
|
| Rate for Payer: Cash Price |
$86.40
|
| Rate for Payer: Cigna Commercial |
$91.20
|
| Rate for Payer: Cigna Medicare |
$86.40
|
| Rate for Payer: Medicaid All Medicaid |
$88.32
|
| Rate for Payer: Medicare All Medicare |
$67.20
|
| Rate for Payer: Monida Allegiance |
$91.20
|
| Rate for Payer: Monida First Choice Health |
$93.12
|
| Rate for Payer: Monida Montana Health Co-op |
$91.20
|
| Rate for Payer: Monida PacificSource |
$91.20
|
|
|
EXTRCBL NUCL AG-EACH AB ANY METH 86235
|
Facility
|
OP
|
$114.00
|
|
|
Service Code
|
CPT 86235
|
| Hospital Charge Code |
4086235
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$79.80 |
| Max. Negotiated Rate |
$114.00 |
| Rate for Payer: Aetna Commercial |
$108.30
|
| Rate for Payer: Aetna Medicare |
$102.60
|
| Rate for Payer: BCBS MT CHIP |
$102.60
|
| Rate for Payer: BCBS MT Closed Plan Network |
$108.30
|
| Rate for Payer: BCBS MT HealthLink |
$102.60
|
| Rate for Payer: BCBS MT Medicare |
$102.60
|
| Rate for Payer: BCBS MT POS |
$108.30
|
| Rate for Payer: BCBS MT Traditional |
$114.00
|
| Rate for Payer: Cash Price |
$102.60
|
| Rate for Payer: Cigna Commercial |
$108.30
|
| Rate for Payer: Cigna Medicare |
$102.60
|
| Rate for Payer: Medicaid All Medicaid |
$104.88
|
| Rate for Payer: Medicare All Medicare |
$79.80
|
| Rate for Payer: Monida Allegiance |
$108.30
|
| Rate for Payer: Monida First Choice Health |
$110.58
|
| Rate for Payer: Monida Montana Health Co-op |
$108.30
|
| Rate for Payer: Monida PacificSource |
$108.30
|
|
|
EXTRCBL NUCL AG-EACH AB ANY METH 86235
|
Facility
|
IP
|
$114.00
|
|
|
Service Code
|
CPT 86235
|
| Hospital Charge Code |
4086235
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$79.80 |
| Max. Negotiated Rate |
$114.00 |
| Rate for Payer: Aetna Commercial |
$108.30
|
| Rate for Payer: Aetna Medicare |
$102.60
|
| Rate for Payer: BCBS MT CHIP |
$102.60
|
| Rate for Payer: BCBS MT Closed Plan Network |
$108.30
|
| Rate for Payer: BCBS MT HealthLink |
$102.60
|
| Rate for Payer: BCBS MT Medicare |
$102.60
|
| Rate for Payer: BCBS MT POS |
$108.30
|
| Rate for Payer: BCBS MT Traditional |
$114.00
|
| Rate for Payer: Cash Price |
$102.60
|
| Rate for Payer: Cigna Commercial |
$108.30
|
| Rate for Payer: Cigna Medicare |
$102.60
|
| Rate for Payer: Medicaid All Medicaid |
$104.88
|
| Rate for Payer: Medicare All Medicare |
$79.80
|
| Rate for Payer: Monida Allegiance |
$108.30
|
| Rate for Payer: Monida First Choice Health |
$110.58
|
| Rate for Payer: Monida Montana Health Co-op |
$108.30
|
| Rate for Payer: Monida PacificSource |
$108.30
|
|
|
EYE PADS
|
Facility
|
OP
|
$4.00
|
|
| Hospital Charge Code |
80030173
|
|
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
|
|
|
EYE PADS
|
Facility
|
IP
|
$4.00
|
|
| Hospital Charge Code |
80030173
|
|
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
|
|
|
EYE STREAM IRRIGATING RINSE [4 OZ]
|
Facility
|
OP
|
$117.00
|
|
|
Service Code
|
HCPCS A9150
|
| Hospital Charge Code |
3000171
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$81.90 |
| Max. Negotiated Rate |
$117.00 |
| Rate for Payer: Aetna Commercial |
$111.15
|
| Rate for Payer: Aetna Medicare |
$105.30
|
| Rate for Payer: BCBS MT CHIP |
$105.30
|
| Rate for Payer: BCBS MT Closed Plan Network |
$111.15
|
| Rate for Payer: BCBS MT HealthLink |
$105.30
|
| Rate for Payer: BCBS MT Medicare |
$105.30
|
| Rate for Payer: BCBS MT POS |
$111.15
|
| Rate for Payer: BCBS MT Traditional |
$117.00
|
| Rate for Payer: Cash Price |
$105.30
|
| Rate for Payer: Cigna Commercial |
$111.15
|
| Rate for Payer: Cigna Medicare |
$105.30
|
| Rate for Payer: Medicaid All Medicaid |
$107.64
|
| Rate for Payer: Medicare All Medicare |
$81.90
|
| Rate for Payer: Monida Allegiance |
$111.15
|
| Rate for Payer: Monida First Choice Health |
$113.49
|
| Rate for Payer: Monida Montana Health Co-op |
$111.15
|
| Rate for Payer: Monida PacificSource |
$111.15
|
|
|
EYE STREAM IRRIGATING RINSE [4 OZ]
|
Facility
|
IP
|
$117.00
|
|
|
Service Code
|
HCPCS A9150
|
| Hospital Charge Code |
3000171
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$81.90 |
| Max. Negotiated Rate |
$117.00 |
| Rate for Payer: Aetna Commercial |
$111.15
|
| Rate for Payer: Aetna Medicare |
$105.30
|
| Rate for Payer: BCBS MT CHIP |
$105.30
|
| Rate for Payer: BCBS MT Closed Plan Network |
$111.15
|
| Rate for Payer: BCBS MT HealthLink |
$105.30
|
| Rate for Payer: BCBS MT Medicare |
$105.30
|
| Rate for Payer: BCBS MT POS |
$111.15
|
| Rate for Payer: BCBS MT Traditional |
$117.00
|
| Rate for Payer: Cash Price |
$105.30
|
| Rate for Payer: Cigna Commercial |
$111.15
|
| Rate for Payer: Cigna Medicare |
$105.30
|
| Rate for Payer: Medicaid All Medicaid |
$107.64
|
| Rate for Payer: Medicare All Medicare |
$81.90
|
| Rate for Payer: Monida Allegiance |
$111.15
|
| Rate for Payer: Monida First Choice Health |
$113.49
|
| Rate for Payer: Monida Montana Health Co-op |
$111.15
|
| Rate for Payer: Monida PacificSource |
$111.15
|
|
|
EZETIMIBE TAB [10 MG] NF
|
Facility
|
OP
|
$17.00
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
3000505
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.90 |
| Max. Negotiated Rate |
$17.00 |
| Rate for Payer: Aetna Commercial |
$16.15
|
| Rate for Payer: Aetna Medicare |
$15.30
|
| Rate for Payer: BCBS MT CHIP |
$15.30
|
| Rate for Payer: BCBS MT Closed Plan Network |
$16.15
|
| Rate for Payer: BCBS MT HealthLink |
$15.30
|
| Rate for Payer: BCBS MT Medicare |
$15.30
|
| Rate for Payer: BCBS MT POS |
$16.15
|
| Rate for Payer: BCBS MT Traditional |
$17.00
|
| Rate for Payer: Cash Price |
$15.30
|
| Rate for Payer: Cigna Commercial |
$16.15
|
| Rate for Payer: Cigna Medicare |
$15.30
|
| Rate for Payer: Medicaid All Medicaid |
$15.64
|
| Rate for Payer: Medicare All Medicare |
$11.90
|
| Rate for Payer: Monida Allegiance |
$16.15
|
| Rate for Payer: Monida First Choice Health |
$16.49
|
| Rate for Payer: Monida Montana Health Co-op |
$16.15
|
| Rate for Payer: Monida PacificSource |
$16.15
|
|
|
EZETIMIBE TAB [10 MG] NF
|
Facility
|
IP
|
$17.00
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
3000505
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.90 |
| Max. Negotiated Rate |
$17.00 |
| Rate for Payer: Aetna Commercial |
$16.15
|
| Rate for Payer: Aetna Medicare |
$15.30
|
| Rate for Payer: BCBS MT CHIP |
$15.30
|
| Rate for Payer: BCBS MT Closed Plan Network |
$16.15
|
| Rate for Payer: BCBS MT HealthLink |
$15.30
|
| Rate for Payer: BCBS MT Medicare |
$15.30
|
| Rate for Payer: BCBS MT POS |
$16.15
|
| Rate for Payer: BCBS MT Traditional |
$17.00
|
| Rate for Payer: Cash Price |
$15.30
|
| Rate for Payer: Cigna Commercial |
$16.15
|
| Rate for Payer: Cigna Medicare |
$15.30
|
| Rate for Payer: Medicaid All Medicaid |
$15.64
|
| Rate for Payer: Medicare All Medicare |
$11.90
|
| Rate for Payer: Monida Allegiance |
$16.15
|
| Rate for Payer: Monida First Choice Health |
$16.49
|
| Rate for Payer: Monida Montana Health Co-op |
$16.15
|
| Rate for Payer: Monida PacificSource |
$16.15
|
|
|
EZ SCRUB
|
Facility
|
IP
|
$4.00
|
|
| Hospital Charge Code |
80030499
|
|
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
|
|
|
EZ SCRUB
|
Facility
|
OP
|
$4.00
|
|
| Hospital Charge Code |
80030499
|
|
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
|
|
|
EZ WRAP FOAM TUBES
|
Facility
|
OP
|
$11.00
|
|
| Hospital Charge Code |
80040106
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$7.70 |
| Max. Negotiated Rate |
$11.00 |
| Rate for Payer: Aetna Commercial |
$10.45
|
| Rate for Payer: Aetna Medicare |
$9.90
|
| Rate for Payer: BCBS MT CHIP |
$9.90
|
| Rate for Payer: BCBS MT Closed Plan Network |
$10.45
|
| Rate for Payer: BCBS MT HealthLink |
$9.90
|
| Rate for Payer: BCBS MT Medicare |
$9.90
|
| Rate for Payer: BCBS MT POS |
$10.45
|
| Rate for Payer: BCBS MT Traditional |
$11.00
|
| Rate for Payer: Cash Price |
$9.90
|
| Rate for Payer: Cigna Commercial |
$10.45
|
| Rate for Payer: Cigna Medicare |
$9.90
|
| Rate for Payer: Medicaid All Medicaid |
$10.12
|
| Rate for Payer: Medicare All Medicare |
$7.70
|
| Rate for Payer: Monida Allegiance |
$10.45
|
| Rate for Payer: Monida First Choice Health |
$10.67
|
| Rate for Payer: Monida Montana Health Co-op |
$10.45
|
| Rate for Payer: Monida PacificSource |
$10.45
|
|
|
EZ WRAP FOAM TUBES
|
Facility
|
IP
|
$11.00
|
|
| Hospital Charge Code |
80040106
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$7.70 |
| Max. Negotiated Rate |
$11.00 |
| Rate for Payer: Aetna Commercial |
$10.45
|
| Rate for Payer: Aetna Medicare |
$9.90
|
| Rate for Payer: BCBS MT CHIP |
$9.90
|
| Rate for Payer: BCBS MT Closed Plan Network |
$10.45
|
| Rate for Payer: BCBS MT HealthLink |
$9.90
|
| Rate for Payer: BCBS MT Medicare |
$9.90
|
| Rate for Payer: BCBS MT POS |
$10.45
|
| Rate for Payer: BCBS MT Traditional |
$11.00
|
| Rate for Payer: Cash Price |
$9.90
|
| Rate for Payer: Cigna Commercial |
$10.45
|
| Rate for Payer: Cigna Medicare |
$9.90
|
| Rate for Payer: Medicaid All Medicaid |
$10.12
|
| Rate for Payer: Medicare All Medicare |
$7.70
|
| Rate for Payer: Monida Allegiance |
$10.45
|
| Rate for Payer: Monida First Choice Health |
$10.67
|
| Rate for Payer: Monida Montana Health Co-op |
$10.45
|
| Rate for Payer: Monida PacificSource |
$10.45
|
|
|
FACTOR IX ACTIVITY (086298)
|
Facility
|
IP
|
$197.00
|
|
|
Service Code
|
CPT 85250
|
| Hospital Charge Code |
4085250
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$137.90 |
| Max. Negotiated Rate |
$197.00 |
| Rate for Payer: Aetna Commercial |
$187.15
|
| Rate for Payer: Aetna Medicare |
$177.30
|
| Rate for Payer: BCBS MT CHIP |
$177.30
|
| Rate for Payer: BCBS MT Closed Plan Network |
$187.15
|
| Rate for Payer: BCBS MT HealthLink |
$177.30
|
| Rate for Payer: BCBS MT Medicare |
$177.30
|
| Rate for Payer: BCBS MT POS |
$187.15
|
| Rate for Payer: BCBS MT Traditional |
$197.00
|
| Rate for Payer: Cash Price |
$177.30
|
| Rate for Payer: Cigna Commercial |
$187.15
|
| Rate for Payer: Cigna Medicare |
$177.30
|
| Rate for Payer: Medicaid All Medicaid |
$181.24
|
| Rate for Payer: Medicare All Medicare |
$137.90
|
| Rate for Payer: Monida Allegiance |
$187.15
|
| Rate for Payer: Monida First Choice Health |
$191.09
|
| Rate for Payer: Monida Montana Health Co-op |
$187.15
|
| Rate for Payer: Monida PacificSource |
$187.15
|
|
|
FACTOR IX ACTIVITY (086298)
|
Facility
|
OP
|
$197.00
|
|
|
Service Code
|
CPT 85250
|
| Hospital Charge Code |
4085250
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$137.90 |
| Max. Negotiated Rate |
$197.00 |
| Rate for Payer: Aetna Commercial |
$187.15
|
| Rate for Payer: Aetna Medicare |
$177.30
|
| Rate for Payer: BCBS MT CHIP |
$177.30
|
| Rate for Payer: BCBS MT Closed Plan Network |
$187.15
|
| Rate for Payer: BCBS MT HealthLink |
$177.30
|
| Rate for Payer: BCBS MT Medicare |
$177.30
|
| Rate for Payer: BCBS MT POS |
$187.15
|
| Rate for Payer: BCBS MT Traditional |
$197.00
|
| Rate for Payer: Cash Price |
$177.30
|
| Rate for Payer: Cigna Commercial |
$187.15
|
| Rate for Payer: Cigna Medicare |
$177.30
|
| Rate for Payer: Medicaid All Medicaid |
$181.24
|
| Rate for Payer: Medicare All Medicare |
$137.90
|
| Rate for Payer: Monida Allegiance |
$187.15
|
| Rate for Payer: Monida First Choice Health |
$191.09
|
| Rate for Payer: Monida Montana Health Co-op |
$187.15
|
| Rate for Payer: Monida PacificSource |
$187.15
|
|
|
FACTOR V ACTIVITY (086249)
|
Facility
|
OP
|
$197.00
|
|
|
Service Code
|
CPT 85220
|
| Hospital Charge Code |
4085397
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$137.90 |
| Max. Negotiated Rate |
$197.00 |
| Rate for Payer: Aetna Commercial |
$187.15
|
| Rate for Payer: Aetna Medicare |
$177.30
|
| Rate for Payer: BCBS MT CHIP |
$177.30
|
| Rate for Payer: BCBS MT Closed Plan Network |
$187.15
|
| Rate for Payer: BCBS MT HealthLink |
$177.30
|
| Rate for Payer: BCBS MT Medicare |
$177.30
|
| Rate for Payer: BCBS MT POS |
$187.15
|
| Rate for Payer: BCBS MT Traditional |
$197.00
|
| Rate for Payer: Cash Price |
$177.30
|
| Rate for Payer: Cigna Commercial |
$187.15
|
| Rate for Payer: Cigna Medicare |
$177.30
|
| Rate for Payer: Medicaid All Medicaid |
$181.24
|
| Rate for Payer: Medicare All Medicare |
$137.90
|
| Rate for Payer: Monida Allegiance |
$187.15
|
| Rate for Payer: Monida First Choice Health |
$191.09
|
| Rate for Payer: Monida Montana Health Co-op |
$187.15
|
| Rate for Payer: Monida PacificSource |
$187.15
|
|
|
FACTOR V ACTIVITY (086249)
|
Facility
|
IP
|
$197.00
|
|
|
Service Code
|
CPT 85220
|
| Hospital Charge Code |
4085397
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$137.90 |
| Max. Negotiated Rate |
$197.00 |
| Rate for Payer: Aetna Commercial |
$187.15
|
| Rate for Payer: Aetna Medicare |
$177.30
|
| Rate for Payer: BCBS MT CHIP |
$177.30
|
| Rate for Payer: BCBS MT Closed Plan Network |
$187.15
|
| Rate for Payer: BCBS MT HealthLink |
$177.30
|
| Rate for Payer: BCBS MT Medicare |
$177.30
|
| Rate for Payer: BCBS MT POS |
$187.15
|
| Rate for Payer: BCBS MT Traditional |
$197.00
|
| Rate for Payer: Cash Price |
$177.30
|
| Rate for Payer: Cigna Commercial |
$187.15
|
| Rate for Payer: Cigna Medicare |
$177.30
|
| Rate for Payer: Medicaid All Medicaid |
$181.24
|
| Rate for Payer: Medicare All Medicare |
$137.90
|
| Rate for Payer: Monida Allegiance |
$187.15
|
| Rate for Payer: Monida First Choice Health |
$191.09
|
| Rate for Payer: Monida Montana Health Co-op |
$187.15
|
| Rate for Payer: Monida PacificSource |
$187.15
|
|
|
FACTOR VIII ACTIVITY
|
Facility
|
IP
|
$90.00
|
|
|
Service Code
|
CPT 85240
|
| Hospital Charge Code |
4088057
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$63.00 |
| Max. Negotiated Rate |
$90.00 |
| Rate for Payer: Aetna Commercial |
$85.50
|
| Rate for Payer: Aetna Medicare |
$81.00
|
| Rate for Payer: BCBS MT CHIP |
$81.00
|
| Rate for Payer: BCBS MT Closed Plan Network |
$85.50
|
| Rate for Payer: BCBS MT HealthLink |
$81.00
|
| Rate for Payer: BCBS MT Medicare |
$81.00
|
| Rate for Payer: BCBS MT POS |
$85.50
|
| Rate for Payer: BCBS MT Traditional |
$90.00
|
| Rate for Payer: Cash Price |
$81.00
|
| Rate for Payer: Cigna Commercial |
$85.50
|
| Rate for Payer: Cigna Medicare |
$81.00
|
| Rate for Payer: Medicaid All Medicaid |
$82.80
|
| Rate for Payer: Medicare All Medicare |
$63.00
|
| Rate for Payer: Monida Allegiance |
$85.50
|
| Rate for Payer: Monida First Choice Health |
$87.30
|
| Rate for Payer: Monida Montana Health Co-op |
$85.50
|
| Rate for Payer: Monida PacificSource |
$85.50
|
|
|
FACTOR VIII ACTIVITY
|
Facility
|
OP
|
$90.00
|
|
|
Service Code
|
CPT 85240
|
| Hospital Charge Code |
4088057
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$63.00 |
| Max. Negotiated Rate |
$90.00 |
| Rate for Payer: Aetna Commercial |
$85.50
|
| Rate for Payer: Aetna Medicare |
$81.00
|
| Rate for Payer: BCBS MT CHIP |
$81.00
|
| Rate for Payer: BCBS MT Closed Plan Network |
$85.50
|
| Rate for Payer: BCBS MT HealthLink |
$81.00
|
| Rate for Payer: BCBS MT Medicare |
$81.00
|
| Rate for Payer: BCBS MT POS |
$85.50
|
| Rate for Payer: BCBS MT Traditional |
$90.00
|
| Rate for Payer: Cash Price |
$81.00
|
| Rate for Payer: Cigna Commercial |
$85.50
|
| Rate for Payer: Cigna Medicare |
$81.00
|
| Rate for Payer: Medicaid All Medicaid |
$82.80
|
| Rate for Payer: Medicare All Medicare |
$63.00
|
| Rate for Payer: Monida Allegiance |
$85.50
|
| Rate for Payer: Monida First Choice Health |
$87.30
|
| Rate for Payer: Monida Montana Health Co-op |
$85.50
|
| Rate for Payer: Monida PacificSource |
$85.50
|
|
|
FACTOR VIII ASSAY (086264)
|
Facility
|
OP
|
$90.00
|
|
|
Service Code
|
CPT 85240
|
| Hospital Charge Code |
4085240
|
|
Hospital Revenue Code
|
305
|
| Min. Negotiated Rate |
$63.00 |
| Max. Negotiated Rate |
$90.00 |
| Rate for Payer: Aetna Commercial |
$85.50
|
| Rate for Payer: Aetna Medicare |
$81.00
|
| Rate for Payer: BCBS MT CHIP |
$81.00
|
| Rate for Payer: BCBS MT Closed Plan Network |
$85.50
|
| Rate for Payer: BCBS MT HealthLink |
$81.00
|
| Rate for Payer: BCBS MT Medicare |
$81.00
|
| Rate for Payer: BCBS MT POS |
$85.50
|
| Rate for Payer: BCBS MT Traditional |
$90.00
|
| Rate for Payer: Cash Price |
$81.00
|
| Rate for Payer: Cigna Commercial |
$85.50
|
| Rate for Payer: Cigna Medicare |
$81.00
|
| Rate for Payer: Medicaid All Medicaid |
$82.80
|
| Rate for Payer: Medicare All Medicare |
$63.00
|
| Rate for Payer: Monida Allegiance |
$85.50
|
| Rate for Payer: Monida First Choice Health |
$87.30
|
| Rate for Payer: Monida Montana Health Co-op |
$85.50
|
| Rate for Payer: Monida PacificSource |
$85.50
|
|
|
FACTOR VIII ASSAY (086264)
|
Facility
|
IP
|
$90.00
|
|
|
Service Code
|
CPT 85240
|
| Hospital Charge Code |
4085240
|
|
Hospital Revenue Code
|
305
|
| Min. Negotiated Rate |
$63.00 |
| Max. Negotiated Rate |
$90.00 |
| Rate for Payer: Aetna Commercial |
$85.50
|
| Rate for Payer: Aetna Medicare |
$81.00
|
| Rate for Payer: BCBS MT CHIP |
$81.00
|
| Rate for Payer: BCBS MT Closed Plan Network |
$85.50
|
| Rate for Payer: BCBS MT HealthLink |
$81.00
|
| Rate for Payer: BCBS MT Medicare |
$81.00
|
| Rate for Payer: BCBS MT POS |
$85.50
|
| Rate for Payer: BCBS MT Traditional |
$90.00
|
| Rate for Payer: Cash Price |
$81.00
|
| Rate for Payer: Cigna Commercial |
$85.50
|
| Rate for Payer: Cigna Medicare |
$81.00
|
| Rate for Payer: Medicaid All Medicaid |
$82.80
|
| Rate for Payer: Medicare All Medicare |
$63.00
|
| Rate for Payer: Monida Allegiance |
$85.50
|
| Rate for Payer: Monida First Choice Health |
$87.30
|
| Rate for Payer: Monida Montana Health Co-op |
$85.50
|
| Rate for Payer: Monida PacificSource |
$85.50
|
|
