|
GROUP A STREP SCREEN, RAPID TEST
|
Facility
|
OP
|
$111.00
|
|
|
Service Code
|
CPT 87880
|
| Hospital Charge Code |
4087880
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$77.70 |
| Max. Negotiated Rate |
$111.00 |
| Rate for Payer: Aetna Commercial |
$105.45
|
| Rate for Payer: Aetna Medicare |
$99.90
|
| Rate for Payer: BCBS MT CHIP |
$99.90
|
| Rate for Payer: BCBS MT Closed Plan Network |
$105.45
|
| Rate for Payer: BCBS MT HealthLink |
$99.90
|
| Rate for Payer: BCBS MT Medicare |
$99.90
|
| Rate for Payer: BCBS MT POS |
$105.45
|
| Rate for Payer: BCBS MT Traditional |
$111.00
|
| Rate for Payer: Cash Price |
$99.90
|
| Rate for Payer: Cigna Commercial |
$105.45
|
| Rate for Payer: Cigna Medicare |
$99.90
|
| Rate for Payer: Medicaid All Medicaid |
$102.12
|
| Rate for Payer: Medicare All Medicare |
$77.70
|
| Rate for Payer: Monida Allegiance |
$105.45
|
| Rate for Payer: Monida First Choice Health |
$107.67
|
| Rate for Payer: Monida Montana Health Co-op |
$105.45
|
| Rate for Payer: Monida PacificSource |
$105.45
|
|
|
GROUP A STREP SCREEN, RAPID TEST
|
Facility
|
IP
|
$111.00
|
|
|
Service Code
|
CPT 87880
|
| Hospital Charge Code |
4087880
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$77.70 |
| Max. Negotiated Rate |
$111.00 |
| Rate for Payer: Aetna Commercial |
$105.45
|
| Rate for Payer: Aetna Medicare |
$99.90
|
| Rate for Payer: BCBS MT CHIP |
$99.90
|
| Rate for Payer: BCBS MT Closed Plan Network |
$105.45
|
| Rate for Payer: BCBS MT HealthLink |
$99.90
|
| Rate for Payer: BCBS MT Medicare |
$99.90
|
| Rate for Payer: BCBS MT POS |
$105.45
|
| Rate for Payer: BCBS MT Traditional |
$111.00
|
| Rate for Payer: Cash Price |
$99.90
|
| Rate for Payer: Cigna Commercial |
$105.45
|
| Rate for Payer: Cigna Medicare |
$99.90
|
| Rate for Payer: Medicaid All Medicaid |
$102.12
|
| Rate for Payer: Medicare All Medicare |
$77.70
|
| Rate for Payer: Monida Allegiance |
$105.45
|
| Rate for Payer: Monida First Choice Health |
$107.67
|
| Rate for Payer: Monida Montana Health Co-op |
$105.45
|
| Rate for Payer: Monida PacificSource |
$105.45
|
|
|
GROUP B STREP CULTURE BCL
|
Facility
|
OP
|
$84.00
|
|
|
Service Code
|
CPT 87081
|
| Hospital Charge Code |
4087947
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$58.80 |
| Max. Negotiated Rate |
$84.00 |
| Rate for Payer: Aetna Commercial |
$79.80
|
| Rate for Payer: Aetna Medicare |
$75.60
|
| Rate for Payer: BCBS MT CHIP |
$75.60
|
| Rate for Payer: BCBS MT Closed Plan Network |
$79.80
|
| Rate for Payer: BCBS MT HealthLink |
$75.60
|
| Rate for Payer: BCBS MT Medicare |
$75.60
|
| Rate for Payer: BCBS MT POS |
$79.80
|
| Rate for Payer: BCBS MT Traditional |
$84.00
|
| Rate for Payer: Cash Price |
$75.60
|
| Rate for Payer: Cigna Commercial |
$79.80
|
| Rate for Payer: Cigna Medicare |
$75.60
|
| Rate for Payer: Medicaid All Medicaid |
$77.28
|
| Rate for Payer: Medicare All Medicare |
$58.80
|
| Rate for Payer: Monida Allegiance |
$79.80
|
| Rate for Payer: Monida First Choice Health |
$81.48
|
| Rate for Payer: Monida Montana Health Co-op |
$79.80
|
| Rate for Payer: Monida PacificSource |
$79.80
|
|
|
GROUP B STREP CULTURE BCL
|
Facility
|
IP
|
$84.00
|
|
|
Service Code
|
CPT 87081
|
| Hospital Charge Code |
4087947
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$58.80 |
| Max. Negotiated Rate |
$84.00 |
| Rate for Payer: Aetna Commercial |
$79.80
|
| Rate for Payer: Aetna Medicare |
$75.60
|
| Rate for Payer: BCBS MT CHIP |
$75.60
|
| Rate for Payer: BCBS MT Closed Plan Network |
$79.80
|
| Rate for Payer: BCBS MT HealthLink |
$75.60
|
| Rate for Payer: BCBS MT Medicare |
$75.60
|
| Rate for Payer: BCBS MT POS |
$79.80
|
| Rate for Payer: BCBS MT Traditional |
$84.00
|
| Rate for Payer: Cash Price |
$75.60
|
| Rate for Payer: Cigna Commercial |
$79.80
|
| Rate for Payer: Cigna Medicare |
$75.60
|
| Rate for Payer: Medicaid All Medicaid |
$77.28
|
| Rate for Payer: Medicare All Medicare |
$58.80
|
| Rate for Payer: Monida Allegiance |
$79.80
|
| Rate for Payer: Monida First Choice Health |
$81.48
|
| Rate for Payer: Monida Montana Health Co-op |
$79.80
|
| Rate for Payer: Monida PacificSource |
$79.80
|
|
|
GROUP THERAPY
|
Facility
|
OP
|
$223.00
|
|
|
Service Code
|
CPT 90853
|
| Hospital Charge Code |
8090853
|
|
Hospital Revenue Code
|
521
|
| 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
|
|
|
GROUP THERAPY
|
Facility
|
IP
|
$223.00
|
|
|
Service Code
|
CPT 90853
|
| Hospital Charge Code |
8090853
|
|
Hospital Revenue Code
|
521
|
| 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
|
|
|
GROWTH HORMONE
|
Facility
|
OP
|
$80.00
|
|
|
Service Code
|
CPT 83003
|
| Hospital Charge Code |
4088010
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$56.00 |
| Max. Negotiated Rate |
$80.00 |
| Rate for Payer: Aetna Commercial |
$76.00
|
| Rate for Payer: Aetna Medicare |
$72.00
|
| Rate for Payer: BCBS MT CHIP |
$72.00
|
| Rate for Payer: BCBS MT Closed Plan Network |
$76.00
|
| Rate for Payer: BCBS MT HealthLink |
$72.00
|
| Rate for Payer: BCBS MT Medicare |
$72.00
|
| Rate for Payer: BCBS MT POS |
$76.00
|
| Rate for Payer: BCBS MT Traditional |
$80.00
|
| Rate for Payer: Cash Price |
$72.00
|
| Rate for Payer: Cigna Commercial |
$76.00
|
| Rate for Payer: Cigna Medicare |
$72.00
|
| Rate for Payer: Medicaid All Medicaid |
$73.60
|
| Rate for Payer: Medicare All Medicare |
$56.00
|
| Rate for Payer: Monida Allegiance |
$76.00
|
| Rate for Payer: Monida First Choice Health |
$77.60
|
| Rate for Payer: Monida Montana Health Co-op |
$76.00
|
| Rate for Payer: Monida PacificSource |
$76.00
|
|
|
GROWTH HORMONE
|
Facility
|
IP
|
$80.00
|
|
|
Service Code
|
CPT 83003
|
| Hospital Charge Code |
4088010
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$56.00 |
| Max. Negotiated Rate |
$80.00 |
| Rate for Payer: Aetna Commercial |
$76.00
|
| Rate for Payer: Aetna Medicare |
$72.00
|
| Rate for Payer: BCBS MT CHIP |
$72.00
|
| Rate for Payer: BCBS MT Closed Plan Network |
$76.00
|
| Rate for Payer: BCBS MT HealthLink |
$72.00
|
| Rate for Payer: BCBS MT Medicare |
$72.00
|
| Rate for Payer: BCBS MT POS |
$76.00
|
| Rate for Payer: BCBS MT Traditional |
$80.00
|
| Rate for Payer: Cash Price |
$72.00
|
| Rate for Payer: Cigna Commercial |
$76.00
|
| Rate for Payer: Cigna Medicare |
$72.00
|
| Rate for Payer: Medicaid All Medicaid |
$73.60
|
| Rate for Payer: Medicare All Medicare |
$56.00
|
| Rate for Payer: Monida Allegiance |
$76.00
|
| Rate for Payer: Monida First Choice Health |
$77.60
|
| Rate for Payer: Monida Montana Health Co-op |
$76.00
|
| Rate for Payer: Monida PacificSource |
$76.00
|
|
|
GUAIFEN/CODEINE LIQ [100MG/10MG 5ML] BTL
|
Facility
|
IP
|
$47.00
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
3000206
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$32.90 |
| Max. Negotiated Rate |
$47.00 |
| Rate for Payer: Aetna Commercial |
$44.65
|
| Rate for Payer: Aetna Medicare |
$42.30
|
| Rate for Payer: BCBS MT CHIP |
$42.30
|
| Rate for Payer: BCBS MT Closed Plan Network |
$44.65
|
| Rate for Payer: BCBS MT HealthLink |
$42.30
|
| Rate for Payer: BCBS MT Medicare |
$42.30
|
| Rate for Payer: BCBS MT POS |
$44.65
|
| Rate for Payer: BCBS MT Traditional |
$47.00
|
| Rate for Payer: Cash Price |
$42.30
|
| Rate for Payer: Cigna Commercial |
$44.65
|
| Rate for Payer: Cigna Medicare |
$42.30
|
| Rate for Payer: Medicaid All Medicaid |
$43.24
|
| Rate for Payer: Medicare All Medicare |
$32.90
|
| Rate for Payer: Monida Allegiance |
$44.65
|
| Rate for Payer: Monida First Choice Health |
$45.59
|
| Rate for Payer: Monida Montana Health Co-op |
$44.65
|
| Rate for Payer: Monida PacificSource |
$44.65
|
|
|
GUAIFEN/CODEINE LIQ [100MG/10MG 5ML] BTL
|
Facility
|
OP
|
$47.00
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
3000206
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$32.90 |
| Max. Negotiated Rate |
$47.00 |
| Rate for Payer: Aetna Commercial |
$44.65
|
| Rate for Payer: Aetna Medicare |
$42.30
|
| Rate for Payer: BCBS MT CHIP |
$42.30
|
| Rate for Payer: BCBS MT Closed Plan Network |
$44.65
|
| Rate for Payer: BCBS MT HealthLink |
$42.30
|
| Rate for Payer: BCBS MT Medicare |
$42.30
|
| Rate for Payer: BCBS MT POS |
$44.65
|
| Rate for Payer: BCBS MT Traditional |
$47.00
|
| Rate for Payer: Cash Price |
$42.30
|
| Rate for Payer: Cigna Commercial |
$44.65
|
| Rate for Payer: Cigna Medicare |
$42.30
|
| Rate for Payer: Medicaid All Medicaid |
$43.24
|
| Rate for Payer: Medicare All Medicare |
$32.90
|
| Rate for Payer: Monida Allegiance |
$44.65
|
| Rate for Payer: Monida First Choice Health |
$45.59
|
| Rate for Payer: Monida Montana Health Co-op |
$44.65
|
| Rate for Payer: Monida PacificSource |
$44.65
|
|
|
GUAIFEN/CODEINE UD CUP [100-10 MG/5 ML]
|
Facility
|
OP
|
$8.00
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
3000207
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.60 |
| Max. Negotiated Rate |
$8.00 |
| Rate for Payer: Aetna Commercial |
$7.60
|
| Rate for Payer: Aetna Medicare |
$7.20
|
| Rate for Payer: BCBS MT CHIP |
$7.20
|
| Rate for Payer: BCBS MT Closed Plan Network |
$7.60
|
| Rate for Payer: BCBS MT HealthLink |
$7.20
|
| Rate for Payer: BCBS MT Medicare |
$7.20
|
| Rate for Payer: BCBS MT POS |
$7.60
|
| Rate for Payer: BCBS MT Traditional |
$8.00
|
| Rate for Payer: Cash Price |
$7.20
|
| Rate for Payer: Cigna Commercial |
$7.60
|
| Rate for Payer: Cigna Medicare |
$7.20
|
| Rate for Payer: Medicaid All Medicaid |
$7.36
|
| Rate for Payer: Medicare All Medicare |
$5.60
|
| Rate for Payer: Monida Allegiance |
$7.60
|
| Rate for Payer: Monida First Choice Health |
$7.76
|
| Rate for Payer: Monida Montana Health Co-op |
$7.60
|
| Rate for Payer: Monida PacificSource |
$7.60
|
|
|
GUAIFEN/CODEINE UD CUP [100-10 MG/5 ML]
|
Facility
|
IP
|
$8.00
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
3000207
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.60 |
| Max. Negotiated Rate |
$8.00 |
| Rate for Payer: Aetna Commercial |
$7.60
|
| Rate for Payer: Aetna Medicare |
$7.20
|
| Rate for Payer: BCBS MT CHIP |
$7.20
|
| Rate for Payer: BCBS MT Closed Plan Network |
$7.60
|
| Rate for Payer: BCBS MT HealthLink |
$7.20
|
| Rate for Payer: BCBS MT Medicare |
$7.20
|
| Rate for Payer: BCBS MT POS |
$7.60
|
| Rate for Payer: BCBS MT Traditional |
$8.00
|
| Rate for Payer: Cash Price |
$7.20
|
| Rate for Payer: Cigna Commercial |
$7.60
|
| Rate for Payer: Cigna Medicare |
$7.20
|
| Rate for Payer: Medicaid All Medicaid |
$7.36
|
| Rate for Payer: Medicare All Medicare |
$5.60
|
| Rate for Payer: Monida Allegiance |
$7.60
|
| Rate for Payer: Monida First Choice Health |
$7.76
|
| Rate for Payer: Monida Montana Health Co-op |
$7.60
|
| Rate for Payer: Monida PacificSource |
$7.60
|
|
|
GUAIFENESIN ER TAB [600 MG]
|
Facility
|
OP
|
$8.00
|
|
|
Service Code
|
HCPCS A9150
|
| Hospital Charge Code |
3000208
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.60 |
| Max. Negotiated Rate |
$8.00 |
| Rate for Payer: Aetna Commercial |
$7.60
|
| Rate for Payer: Aetna Medicare |
$7.20
|
| Rate for Payer: BCBS MT CHIP |
$7.20
|
| Rate for Payer: BCBS MT Closed Plan Network |
$7.60
|
| Rate for Payer: BCBS MT HealthLink |
$7.20
|
| Rate for Payer: BCBS MT Medicare |
$7.20
|
| Rate for Payer: BCBS MT POS |
$7.60
|
| Rate for Payer: BCBS MT Traditional |
$8.00
|
| Rate for Payer: Cash Price |
$7.20
|
| Rate for Payer: Cigna Commercial |
$7.60
|
| Rate for Payer: Cigna Medicare |
$7.20
|
| Rate for Payer: Medicaid All Medicaid |
$7.36
|
| Rate for Payer: Medicare All Medicare |
$5.60
|
| Rate for Payer: Monida Allegiance |
$7.60
|
| Rate for Payer: Monida First Choice Health |
$7.76
|
| Rate for Payer: Monida Montana Health Co-op |
$7.60
|
| Rate for Payer: Monida PacificSource |
$7.60
|
|
|
GUAIFENESIN ER TAB [600 MG]
|
Facility
|
IP
|
$8.00
|
|
|
Service Code
|
HCPCS A9150
|
| Hospital Charge Code |
3000208
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.60 |
| Max. Negotiated Rate |
$8.00 |
| Rate for Payer: Aetna Commercial |
$7.60
|
| Rate for Payer: Aetna Medicare |
$7.20
|
| Rate for Payer: BCBS MT CHIP |
$7.20
|
| Rate for Payer: BCBS MT Closed Plan Network |
$7.60
|
| Rate for Payer: BCBS MT HealthLink |
$7.20
|
| Rate for Payer: BCBS MT Medicare |
$7.20
|
| Rate for Payer: BCBS MT POS |
$7.60
|
| Rate for Payer: BCBS MT Traditional |
$8.00
|
| Rate for Payer: Cash Price |
$7.20
|
| Rate for Payer: Cigna Commercial |
$7.60
|
| Rate for Payer: Cigna Medicare |
$7.20
|
| Rate for Payer: Medicaid All Medicaid |
$7.36
|
| Rate for Payer: Medicare All Medicare |
$5.60
|
| Rate for Payer: Monida Allegiance |
$7.60
|
| Rate for Payer: Monida First Choice Health |
$7.76
|
| Rate for Payer: Monida Montana Health Co-op |
$7.60
|
| Rate for Payer: Monida PacificSource |
$7.60
|
|
|
GUAIFENESIN LIQ [100 MG/5 ML] 118ML BTL
|
Facility
|
OP
|
$24.00
|
|
|
Service Code
|
HCPCS A9150
|
| Hospital Charge Code |
3000209
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$16.80 |
| Max. Negotiated Rate |
$24.00 |
| Rate for Payer: Aetna Commercial |
$22.80
|
| Rate for Payer: Aetna Medicare |
$21.60
|
| Rate for Payer: BCBS MT CHIP |
$21.60
|
| Rate for Payer: BCBS MT Closed Plan Network |
$22.80
|
| Rate for Payer: BCBS MT HealthLink |
$21.60
|
| Rate for Payer: BCBS MT Medicare |
$21.60
|
| Rate for Payer: BCBS MT POS |
$22.80
|
| Rate for Payer: BCBS MT Traditional |
$24.00
|
| Rate for Payer: Cash Price |
$21.60
|
| Rate for Payer: Cigna Commercial |
$22.80
|
| Rate for Payer: Cigna Medicare |
$21.60
|
| Rate for Payer: Medicaid All Medicaid |
$22.08
|
| Rate for Payer: Medicare All Medicare |
$16.80
|
| Rate for Payer: Monida Allegiance |
$22.80
|
| Rate for Payer: Monida First Choice Health |
$23.28
|
| Rate for Payer: Monida Montana Health Co-op |
$22.80
|
| Rate for Payer: Monida PacificSource |
$22.80
|
|
|
GUAIFENESIN LIQ [100 MG/5 ML] 118ML BTL
|
Facility
|
IP
|
$24.00
|
|
|
Service Code
|
HCPCS A9150
|
| Hospital Charge Code |
3000209
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$16.80 |
| Max. Negotiated Rate |
$24.00 |
| Rate for Payer: Aetna Commercial |
$22.80
|
| Rate for Payer: Aetna Medicare |
$21.60
|
| Rate for Payer: BCBS MT CHIP |
$21.60
|
| Rate for Payer: BCBS MT Closed Plan Network |
$22.80
|
| Rate for Payer: BCBS MT HealthLink |
$21.60
|
| Rate for Payer: BCBS MT Medicare |
$21.60
|
| Rate for Payer: BCBS MT POS |
$22.80
|
| Rate for Payer: BCBS MT Traditional |
$24.00
|
| Rate for Payer: Cash Price |
$21.60
|
| Rate for Payer: Cigna Commercial |
$22.80
|
| Rate for Payer: Cigna Medicare |
$21.60
|
| Rate for Payer: Medicaid All Medicaid |
$22.08
|
| Rate for Payer: Medicare All Medicare |
$16.80
|
| Rate for Payer: Monida Allegiance |
$22.80
|
| Rate for Payer: Monida First Choice Health |
$23.28
|
| Rate for Payer: Monida Montana Health Co-op |
$22.80
|
| Rate for Payer: Monida PacificSource |
$22.80
|
|
|
HALDOL UP TO 5MG
|
Facility
|
IP
|
$23.00
|
|
|
Service Code
|
HCPCS J1630
|
| Hospital Charge Code |
8001630
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$16.10 |
| Max. Negotiated Rate |
$23.00 |
| Rate for Payer: Aetna Commercial |
$21.85
|
| Rate for Payer: Aetna Medicare |
$20.70
|
| Rate for Payer: BCBS MT CHIP |
$20.70
|
| Rate for Payer: BCBS MT Closed Plan Network |
$21.85
|
| Rate for Payer: BCBS MT HealthLink |
$20.70
|
| Rate for Payer: BCBS MT Medicare |
$20.70
|
| Rate for Payer: BCBS MT POS |
$21.85
|
| Rate for Payer: BCBS MT Traditional |
$23.00
|
| Rate for Payer: Cash Price |
$20.70
|
| Rate for Payer: Cigna Commercial |
$21.85
|
| Rate for Payer: Cigna Medicare |
$20.70
|
| Rate for Payer: Medicaid All Medicaid |
$21.16
|
| Rate for Payer: Medicare All Medicare |
$16.10
|
| Rate for Payer: Monida Allegiance |
$21.85
|
| Rate for Payer: Monida First Choice Health |
$22.31
|
| Rate for Payer: Monida Montana Health Co-op |
$21.85
|
| Rate for Payer: Monida PacificSource |
$21.85
|
|
|
HALDOL UP TO 5MG
|
Facility
|
OP
|
$23.00
|
|
|
Service Code
|
HCPCS J1630
|
| Hospital Charge Code |
8001630
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$16.10 |
| Max. Negotiated Rate |
$23.00 |
| Rate for Payer: Aetna Commercial |
$21.85
|
| Rate for Payer: Aetna Medicare |
$20.70
|
| Rate for Payer: BCBS MT CHIP |
$20.70
|
| Rate for Payer: BCBS MT Closed Plan Network |
$21.85
|
| Rate for Payer: BCBS MT HealthLink |
$20.70
|
| Rate for Payer: BCBS MT Medicare |
$20.70
|
| Rate for Payer: BCBS MT POS |
$21.85
|
| Rate for Payer: BCBS MT Traditional |
$23.00
|
| Rate for Payer: Cash Price |
$20.70
|
| Rate for Payer: Cigna Commercial |
$21.85
|
| Rate for Payer: Cigna Medicare |
$20.70
|
| Rate for Payer: Medicaid All Medicaid |
$21.16
|
| Rate for Payer: Medicare All Medicare |
$16.10
|
| Rate for Payer: Monida Allegiance |
$21.85
|
| Rate for Payer: Monida First Choice Health |
$22.31
|
| Rate for Payer: Monida Montana Health Co-op |
$21.85
|
| Rate for Payer: Monida PacificSource |
$21.85
|
|
|
HALOPERIDOL INJ [5 MG/ML]
|
Facility
|
IP
|
$26.00
|
|
|
Service Code
|
HCPCS J1630
|
| Hospital Charge Code |
3000210
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$18.20 |
| Max. Negotiated Rate |
$26.00 |
| Rate for Payer: Aetna Commercial |
$24.70
|
| Rate for Payer: Aetna Medicare |
$23.40
|
| Rate for Payer: BCBS MT CHIP |
$23.40
|
| Rate for Payer: BCBS MT Closed Plan Network |
$24.70
|
| Rate for Payer: BCBS MT HealthLink |
$23.40
|
| Rate for Payer: BCBS MT Medicare |
$23.40
|
| Rate for Payer: BCBS MT POS |
$24.70
|
| Rate for Payer: BCBS MT Traditional |
$26.00
|
| Rate for Payer: Cash Price |
$23.40
|
| Rate for Payer: Cigna Commercial |
$24.70
|
| Rate for Payer: Cigna Medicare |
$23.40
|
| Rate for Payer: Medicaid All Medicaid |
$23.92
|
| Rate for Payer: Medicare All Medicare |
$18.20
|
| Rate for Payer: Monida Allegiance |
$24.70
|
| Rate for Payer: Monida First Choice Health |
$25.22
|
| Rate for Payer: Monida Montana Health Co-op |
$24.70
|
| Rate for Payer: Monida PacificSource |
$24.70
|
|
|
HALOPERIDOL INJ [5 MG/ML]
|
Facility
|
OP
|
$26.00
|
|
|
Service Code
|
HCPCS J1630
|
| Hospital Charge Code |
3000210
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$18.20 |
| Max. Negotiated Rate |
$26.00 |
| Rate for Payer: Aetna Commercial |
$24.70
|
| Rate for Payer: Aetna Medicare |
$23.40
|
| Rate for Payer: BCBS MT CHIP |
$23.40
|
| Rate for Payer: BCBS MT Closed Plan Network |
$24.70
|
| Rate for Payer: BCBS MT HealthLink |
$23.40
|
| Rate for Payer: BCBS MT Medicare |
$23.40
|
| Rate for Payer: BCBS MT POS |
$24.70
|
| Rate for Payer: BCBS MT Traditional |
$26.00
|
| Rate for Payer: Cash Price |
$23.40
|
| Rate for Payer: Cigna Commercial |
$24.70
|
| Rate for Payer: Cigna Medicare |
$23.40
|
| Rate for Payer: Medicaid All Medicaid |
$23.92
|
| Rate for Payer: Medicare All Medicare |
$18.20
|
| Rate for Payer: Monida Allegiance |
$24.70
|
| Rate for Payer: Monida First Choice Health |
$25.22
|
| Rate for Payer: Monida Montana Health Co-op |
$24.70
|
| Rate for Payer: Monida PacificSource |
$24.70
|
|
|
HALOPERIDOL TAB [1 MG] NF
|
Facility
|
OP
|
$8.00
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
3000211
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.60 |
| Max. Negotiated Rate |
$8.00 |
| Rate for Payer: Aetna Commercial |
$7.60
|
| Rate for Payer: Aetna Medicare |
$7.20
|
| Rate for Payer: BCBS MT CHIP |
$7.20
|
| Rate for Payer: BCBS MT Closed Plan Network |
$7.60
|
| Rate for Payer: BCBS MT HealthLink |
$7.20
|
| Rate for Payer: BCBS MT Medicare |
$7.20
|
| Rate for Payer: BCBS MT POS |
$7.60
|
| Rate for Payer: BCBS MT Traditional |
$8.00
|
| Rate for Payer: Cash Price |
$7.20
|
| Rate for Payer: Cigna Commercial |
$7.60
|
| Rate for Payer: Cigna Medicare |
$7.20
|
| Rate for Payer: Medicaid All Medicaid |
$7.36
|
| Rate for Payer: Medicare All Medicare |
$5.60
|
| Rate for Payer: Monida Allegiance |
$7.60
|
| Rate for Payer: Monida First Choice Health |
$7.76
|
| Rate for Payer: Monida Montana Health Co-op |
$7.60
|
| Rate for Payer: Monida PacificSource |
$7.60
|
|
|
HALOPERIDOL TAB [1 MG] NF
|
Facility
|
IP
|
$8.00
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
3000211
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.60 |
| Max. Negotiated Rate |
$8.00 |
| Rate for Payer: Aetna Commercial |
$7.60
|
| Rate for Payer: Aetna Medicare |
$7.20
|
| Rate for Payer: BCBS MT CHIP |
$7.20
|
| Rate for Payer: BCBS MT Closed Plan Network |
$7.60
|
| Rate for Payer: BCBS MT HealthLink |
$7.20
|
| Rate for Payer: BCBS MT Medicare |
$7.20
|
| Rate for Payer: BCBS MT POS |
$7.60
|
| Rate for Payer: BCBS MT Traditional |
$8.00
|
| Rate for Payer: Cash Price |
$7.20
|
| Rate for Payer: Cigna Commercial |
$7.60
|
| Rate for Payer: Cigna Medicare |
$7.20
|
| Rate for Payer: Medicaid All Medicaid |
$7.36
|
| Rate for Payer: Medicare All Medicare |
$5.60
|
| Rate for Payer: Monida Allegiance |
$7.60
|
| Rate for Payer: Monida First Choice Health |
$7.76
|
| Rate for Payer: Monida Montana Health Co-op |
$7.60
|
| Rate for Payer: Monida PacificSource |
$7.60
|
|
|
HANDLING FEE PAP SMEAR MCR ONLY
|
Facility
|
OP
|
$98.00
|
|
|
Service Code
|
HCPCS Q0091
|
| Hospital Charge Code |
8000091
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$68.60 |
| Max. Negotiated Rate |
$98.00 |
| Rate for Payer: Aetna Commercial |
$93.10
|
| Rate for Payer: Aetna Medicare |
$88.20
|
| Rate for Payer: BCBS MT CHIP |
$88.20
|
| Rate for Payer: BCBS MT Closed Plan Network |
$93.10
|
| Rate for Payer: BCBS MT HealthLink |
$88.20
|
| Rate for Payer: BCBS MT Medicare |
$88.20
|
| Rate for Payer: BCBS MT POS |
$93.10
|
| Rate for Payer: BCBS MT Traditional |
$98.00
|
| Rate for Payer: Cash Price |
$88.20
|
| Rate for Payer: Cigna Commercial |
$93.10
|
| Rate for Payer: Cigna Medicare |
$88.20
|
| Rate for Payer: Medicaid All Medicaid |
$90.16
|
| Rate for Payer: Medicare All Medicare |
$68.60
|
| Rate for Payer: Monida Allegiance |
$93.10
|
| Rate for Payer: Monida First Choice Health |
$95.06
|
| Rate for Payer: Monida Montana Health Co-op |
$93.10
|
| Rate for Payer: Monida PacificSource |
$93.10
|
|
|
HANDLING FEE PAP SMEAR MCR ONLY
|
Facility
|
IP
|
$98.00
|
|
|
Service Code
|
HCPCS Q0091
|
| Hospital Charge Code |
8000091
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$68.60 |
| Max. Negotiated Rate |
$98.00 |
| Rate for Payer: Aetna Commercial |
$93.10
|
| Rate for Payer: Aetna Medicare |
$88.20
|
| Rate for Payer: BCBS MT CHIP |
$88.20
|
| Rate for Payer: BCBS MT Closed Plan Network |
$93.10
|
| Rate for Payer: BCBS MT HealthLink |
$88.20
|
| Rate for Payer: BCBS MT Medicare |
$88.20
|
| Rate for Payer: BCBS MT POS |
$93.10
|
| Rate for Payer: BCBS MT Traditional |
$98.00
|
| Rate for Payer: Cash Price |
$88.20
|
| Rate for Payer: Cigna Commercial |
$93.10
|
| Rate for Payer: Cigna Medicare |
$88.20
|
| Rate for Payer: Medicaid All Medicaid |
$90.16
|
| Rate for Payer: Medicare All Medicare |
$68.60
|
| Rate for Payer: Monida Allegiance |
$93.10
|
| Rate for Payer: Monida First Choice Health |
$95.06
|
| Rate for Payer: Monida Montana Health Co-op |
$93.10
|
| Rate for Payer: Monida PacificSource |
$93.10
|
|
|
HANDLING FEE SPECIMEN (CLINIC)
|
Facility
|
OP
|
$23.00
|
|
|
Service Code
|
CPT 99000
|
| Hospital Charge Code |
8099000
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$16.10 |
| Max. Negotiated Rate |
$23.00 |
| Rate for Payer: Aetna Commercial |
$21.85
|
| Rate for Payer: Aetna Medicare |
$20.70
|
| Rate for Payer: BCBS MT CHIP |
$20.70
|
| Rate for Payer: BCBS MT Closed Plan Network |
$21.85
|
| Rate for Payer: BCBS MT HealthLink |
$20.70
|
| Rate for Payer: BCBS MT Medicare |
$20.70
|
| Rate for Payer: BCBS MT POS |
$21.85
|
| Rate for Payer: BCBS MT Traditional |
$23.00
|
| Rate for Payer: Cash Price |
$20.70
|
| Rate for Payer: Cigna Commercial |
$21.85
|
| Rate for Payer: Cigna Medicare |
$20.70
|
| Rate for Payer: Medicaid All Medicaid |
$21.16
|
| Rate for Payer: Medicare All Medicare |
$16.10
|
| Rate for Payer: Monida Allegiance |
$21.85
|
| Rate for Payer: Monida First Choice Health |
$22.31
|
| Rate for Payer: Monida Montana Health Co-op |
$21.85
|
| Rate for Payer: Monida PacificSource |
$21.85
|
|
