|
LipoFit by NMR Particle
|
Facility
|
IP
|
$118.00
|
|
|
Service Code
|
HCPCS 83704
|
| Hospital Charge Code |
4087886
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$82.60 |
| Max. Negotiated Rate |
$118.00 |
| Rate for Payer: Aetna Commercial |
$112.10
|
| Rate for Payer: Aetna Medicare |
$106.20
|
| Rate for Payer: BCBS MT CHIP |
$106.20
|
| Rate for Payer: BCBS MT Closed Plan Network |
$112.10
|
| Rate for Payer: BCBS MT HealthLink |
$106.20
|
| Rate for Payer: BCBS MT Medicare |
$106.20
|
| Rate for Payer: BCBS MT POS |
$112.10
|
| Rate for Payer: BCBS MT Traditional |
$118.00
|
| Rate for Payer: Cash Price |
$106.20
|
| Rate for Payer: Cigna Commercial |
$112.10
|
| Rate for Payer: Cigna Medicare |
$106.20
|
| Rate for Payer: Medicaid All Medicaid |
$108.56
|
| Rate for Payer: Medicare All Medicare |
$82.60
|
| Rate for Payer: Monida Allegiance |
$112.10
|
| Rate for Payer: Monida First Choice Health |
$114.46
|
| Rate for Payer: Monida Montana Health Co-op |
$112.10
|
| Rate for Payer: Monida PacificSource |
$112.10
|
|
|
LipoFit by NMR Particle
|
Facility
|
OP
|
$118.00
|
|
|
Service Code
|
HCPCS 83704
|
| Hospital Charge Code |
4087886
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$82.60 |
| Max. Negotiated Rate |
$118.00 |
| Rate for Payer: Aetna Commercial |
$112.10
|
| Rate for Payer: Aetna Medicare |
$106.20
|
| Rate for Payer: BCBS MT CHIP |
$106.20
|
| Rate for Payer: BCBS MT Closed Plan Network |
$112.10
|
| Rate for Payer: BCBS MT HealthLink |
$106.20
|
| Rate for Payer: BCBS MT Medicare |
$106.20
|
| Rate for Payer: BCBS MT POS |
$112.10
|
| Rate for Payer: BCBS MT Traditional |
$118.00
|
| Rate for Payer: Cash Price |
$106.20
|
| Rate for Payer: Cigna Commercial |
$112.10
|
| Rate for Payer: Cigna Medicare |
$106.20
|
| Rate for Payer: Medicaid All Medicaid |
$108.56
|
| Rate for Payer: Medicare All Medicare |
$82.60
|
| Rate for Payer: Monida Allegiance |
$112.10
|
| Rate for Payer: Monida First Choice Health |
$114.46
|
| Rate for Payer: Monida Montana Health Co-op |
$112.10
|
| Rate for Payer: Monida PacificSource |
$112.10
|
|
|
LIPOPROTEIN(a) (120188)
|
Facility
|
IP
|
$42.00
|
|
|
Service Code
|
HCPCS 83695
|
| Hospital Charge Code |
4083695
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$29.40 |
| Max. Negotiated Rate |
$42.00 |
| Rate for Payer: Aetna Commercial |
$39.90
|
| Rate for Payer: Aetna Medicare |
$37.80
|
| Rate for Payer: BCBS MT CHIP |
$37.80
|
| Rate for Payer: BCBS MT Closed Plan Network |
$39.90
|
| Rate for Payer: BCBS MT HealthLink |
$37.80
|
| Rate for Payer: BCBS MT Medicare |
$37.80
|
| Rate for Payer: BCBS MT POS |
$39.90
|
| Rate for Payer: BCBS MT Traditional |
$42.00
|
| Rate for Payer: Cash Price |
$37.80
|
| Rate for Payer: Cigna Commercial |
$39.90
|
| Rate for Payer: Cigna Medicare |
$37.80
|
| Rate for Payer: Medicaid All Medicaid |
$38.64
|
| Rate for Payer: Medicare All Medicare |
$29.40
|
| Rate for Payer: Monida Allegiance |
$39.90
|
| Rate for Payer: Monida First Choice Health |
$40.74
|
| Rate for Payer: Monida Montana Health Co-op |
$39.90
|
| Rate for Payer: Monida PacificSource |
$39.90
|
|
|
LIPOPROTEIN(a) (120188)
|
Facility
|
OP
|
$42.00
|
|
|
Service Code
|
HCPCS 83695
|
| Hospital Charge Code |
4083695
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$29.40 |
| Max. Negotiated Rate |
$42.00 |
| Rate for Payer: Aetna Commercial |
$39.90
|
| Rate for Payer: Aetna Medicare |
$37.80
|
| Rate for Payer: BCBS MT CHIP |
$37.80
|
| Rate for Payer: BCBS MT Closed Plan Network |
$39.90
|
| Rate for Payer: BCBS MT HealthLink |
$37.80
|
| Rate for Payer: BCBS MT Medicare |
$37.80
|
| Rate for Payer: BCBS MT POS |
$39.90
|
| Rate for Payer: BCBS MT Traditional |
$42.00
|
| Rate for Payer: Cash Price |
$37.80
|
| Rate for Payer: Cigna Commercial |
$39.90
|
| Rate for Payer: Cigna Medicare |
$37.80
|
| Rate for Payer: Medicaid All Medicaid |
$38.64
|
| Rate for Payer: Medicare All Medicare |
$29.40
|
| Rate for Payer: Monida Allegiance |
$39.90
|
| Rate for Payer: Monida First Choice Health |
$40.74
|
| Rate for Payer: Monida Montana Health Co-op |
$39.90
|
| Rate for Payer: Monida PacificSource |
$39.90
|
|
|
LIRAGLUTIDE (VICTOZA) 18MG/3ML PEN NF
|
Facility
|
IP
|
$620.00
|
|
|
Service Code
|
HCPCS J1815
|
| Hospital Charge Code |
3007123
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$434.00 |
| Max. Negotiated Rate |
$620.00 |
| Rate for Payer: Aetna Commercial |
$589.00
|
| Rate for Payer: Aetna Medicare |
$558.00
|
| Rate for Payer: BCBS MT CHIP |
$558.00
|
| Rate for Payer: BCBS MT Closed Plan Network |
$589.00
|
| Rate for Payer: BCBS MT HealthLink |
$558.00
|
| Rate for Payer: BCBS MT Medicare |
$558.00
|
| Rate for Payer: BCBS MT POS |
$589.00
|
| Rate for Payer: BCBS MT Traditional |
$620.00
|
| Rate for Payer: Cash Price |
$558.00
|
| Rate for Payer: Cigna Commercial |
$589.00
|
| Rate for Payer: Cigna Medicare |
$558.00
|
| Rate for Payer: Medicaid All Medicaid |
$570.40
|
| Rate for Payer: Medicare All Medicare |
$434.00
|
| Rate for Payer: Monida Allegiance |
$589.00
|
| Rate for Payer: Monida First Choice Health |
$601.40
|
| Rate for Payer: Monida Montana Health Co-op |
$589.00
|
| Rate for Payer: Monida PacificSource |
$589.00
|
|
|
LIRAGLUTIDE (VICTOZA) 18MG/3ML PEN NF
|
Facility
|
OP
|
$620.00
|
|
|
Service Code
|
HCPCS J1815
|
| Hospital Charge Code |
3007123
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$434.00 |
| Max. Negotiated Rate |
$620.00 |
| Rate for Payer: Aetna Commercial |
$589.00
|
| Rate for Payer: Aetna Medicare |
$558.00
|
| Rate for Payer: BCBS MT CHIP |
$558.00
|
| Rate for Payer: BCBS MT Closed Plan Network |
$589.00
|
| Rate for Payer: BCBS MT HealthLink |
$558.00
|
| Rate for Payer: BCBS MT Medicare |
$558.00
|
| Rate for Payer: BCBS MT POS |
$589.00
|
| Rate for Payer: BCBS MT Traditional |
$620.00
|
| Rate for Payer: Cash Price |
$558.00
|
| Rate for Payer: Cigna Commercial |
$589.00
|
| Rate for Payer: Cigna Medicare |
$558.00
|
| Rate for Payer: Medicaid All Medicaid |
$570.40
|
| Rate for Payer: Medicare All Medicare |
$434.00
|
| Rate for Payer: Monida Allegiance |
$589.00
|
| Rate for Payer: Monida First Choice Health |
$601.40
|
| Rate for Payer: Monida Montana Health Co-op |
$589.00
|
| Rate for Payer: Monida PacificSource |
$589.00
|
|
|
LISINOPRIL 2.5MG TAB-NF
|
Facility
|
IP
|
$8.00
|
|
|
Service Code
|
NDC 60687065621
|
| Hospital Charge Code |
3007395
|
|
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
|
|
|
LISINOPRIL 2.5MG TAB-NF
|
Facility
|
OP
|
$8.00
|
|
|
Service Code
|
NDC 60687065621
|
| Hospital Charge Code |
3007395
|
|
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
|
|
|
LISINOPRIL TAB [10 MG]
|
Facility
|
OP
|
$8.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
3000292
|
|
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
|
|
|
LISINOPRIL TAB [10 MG]
|
Facility
|
IP
|
$8.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
3000292
|
|
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
|
|
|
LISINOPRIL TAB [20 MG] NONFORMULARY
|
Facility
|
OP
|
$8.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
3000293
|
|
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
|
|
|
LISINOPRIL TAB [20 MG] NONFORMULARY
|
Facility
|
IP
|
$8.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
3000293
|
|
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
|
|
|
LISINOPRIL TAB [5 MG] NON FORMULARY
|
Facility
|
OP
|
$8.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
3000294
|
|
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
|
|
|
LISINOPRIL TAB [5 MG] NON FORMULARY
|
Facility
|
IP
|
$8.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
3000294
|
|
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
|
|
|
LITHIUM (007708)
|
Facility
|
OP
|
$16.00
|
|
|
Service Code
|
HCPCS 80178
|
| Hospital Charge Code |
4080178
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$11.20 |
| Max. Negotiated Rate |
$16.00 |
| Rate for Payer: Aetna Commercial |
$15.20
|
| Rate for Payer: Aetna Medicare |
$14.40
|
| Rate for Payer: BCBS MT CHIP |
$14.40
|
| Rate for Payer: BCBS MT Closed Plan Network |
$15.20
|
| Rate for Payer: BCBS MT HealthLink |
$14.40
|
| Rate for Payer: BCBS MT Medicare |
$14.40
|
| Rate for Payer: BCBS MT POS |
$15.20
|
| Rate for Payer: BCBS MT Traditional |
$16.00
|
| Rate for Payer: Cash Price |
$14.40
|
| Rate for Payer: Cigna Commercial |
$15.20
|
| Rate for Payer: Cigna Medicare |
$14.40
|
| Rate for Payer: Medicaid All Medicaid |
$14.72
|
| Rate for Payer: Medicare All Medicare |
$11.20
|
| Rate for Payer: Monida Allegiance |
$15.20
|
| Rate for Payer: Monida First Choice Health |
$15.52
|
| Rate for Payer: Monida Montana Health Co-op |
$15.20
|
| Rate for Payer: Monida PacificSource |
$15.20
|
|
|
LITHIUM (007708)
|
Facility
|
IP
|
$16.00
|
|
|
Service Code
|
HCPCS 80178
|
| Hospital Charge Code |
4080178
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$11.20 |
| Max. Negotiated Rate |
$16.00 |
| Rate for Payer: Aetna Commercial |
$15.20
|
| Rate for Payer: Aetna Medicare |
$14.40
|
| Rate for Payer: BCBS MT CHIP |
$14.40
|
| Rate for Payer: BCBS MT Closed Plan Network |
$15.20
|
| Rate for Payer: BCBS MT HealthLink |
$14.40
|
| Rate for Payer: BCBS MT Medicare |
$14.40
|
| Rate for Payer: BCBS MT POS |
$15.20
|
| Rate for Payer: BCBS MT Traditional |
$16.00
|
| Rate for Payer: Cash Price |
$14.40
|
| Rate for Payer: Cigna Commercial |
$15.20
|
| Rate for Payer: Cigna Medicare |
$14.40
|
| Rate for Payer: Medicaid All Medicaid |
$14.72
|
| Rate for Payer: Medicare All Medicare |
$11.20
|
| Rate for Payer: Monida Allegiance |
$15.20
|
| Rate for Payer: Monida First Choice Health |
$15.52
|
| Rate for Payer: Monida Montana Health Co-op |
$15.20
|
| Rate for Payer: Monida PacificSource |
$15.20
|
|
|
LIVER FIBROSIS BIOMARKER PANEL 81517
|
Facility
|
OP
|
$394.00
|
|
|
Service Code
|
HCPCS 81517
|
| Hospital Charge Code |
4081517
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$275.80 |
| Max. Negotiated Rate |
$394.00 |
| Rate for Payer: Aetna Commercial |
$374.30
|
| Rate for Payer: Aetna Medicare |
$354.60
|
| Rate for Payer: BCBS MT CHIP |
$354.60
|
| Rate for Payer: BCBS MT Closed Plan Network |
$374.30
|
| Rate for Payer: BCBS MT HealthLink |
$354.60
|
| Rate for Payer: BCBS MT Medicare |
$354.60
|
| Rate for Payer: BCBS MT POS |
$374.30
|
| Rate for Payer: BCBS MT Traditional |
$394.00
|
| Rate for Payer: Cash Price |
$354.60
|
| Rate for Payer: Cigna Commercial |
$374.30
|
| Rate for Payer: Cigna Medicare |
$354.60
|
| Rate for Payer: Medicaid All Medicaid |
$362.48
|
| Rate for Payer: Medicare All Medicare |
$275.80
|
| Rate for Payer: Monida Allegiance |
$374.30
|
| Rate for Payer: Monida First Choice Health |
$382.18
|
| Rate for Payer: Monida Montana Health Co-op |
$374.30
|
| Rate for Payer: Monida PacificSource |
$374.30
|
|
|
LIVER FIBROSIS BIOMARKER PANEL 81517
|
Facility
|
IP
|
$394.00
|
|
|
Service Code
|
HCPCS 81517
|
| Hospital Charge Code |
4081517
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$275.80 |
| Max. Negotiated Rate |
$394.00 |
| Rate for Payer: Aetna Commercial |
$374.30
|
| Rate for Payer: Aetna Medicare |
$354.60
|
| Rate for Payer: BCBS MT CHIP |
$354.60
|
| Rate for Payer: BCBS MT Closed Plan Network |
$374.30
|
| Rate for Payer: BCBS MT HealthLink |
$354.60
|
| Rate for Payer: BCBS MT Medicare |
$354.60
|
| Rate for Payer: BCBS MT POS |
$374.30
|
| Rate for Payer: BCBS MT Traditional |
$394.00
|
| Rate for Payer: Cash Price |
$354.60
|
| Rate for Payer: Cigna Commercial |
$374.30
|
| Rate for Payer: Cigna Medicare |
$354.60
|
| Rate for Payer: Medicaid All Medicaid |
$362.48
|
| Rate for Payer: Medicare All Medicare |
$275.80
|
| Rate for Payer: Monida Allegiance |
$374.30
|
| Rate for Payer: Monida First Choice Health |
$382.18
|
| Rate for Payer: Monida Montana Health Co-op |
$374.30
|
| Rate for Payer: Monida PacificSource |
$374.30
|
|
|
LIVER-KIDNEY MICROSOMAL AB (006676)
|
Facility
|
IP
|
$23.00
|
|
|
Service Code
|
HCPCS 86376
|
| Hospital Charge Code |
4063761
|
|
Hospital Revenue Code
|
300
|
| 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
|
|
|
LIVER-KIDNEY MICROSOMAL AB (006676)
|
Facility
|
OP
|
$23.00
|
|
|
Service Code
|
HCPCS 86376
|
| Hospital Charge Code |
4063761
|
|
Hospital Revenue Code
|
300
|
| 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
|
|
|
LOPERAMIDE CAP [2 MG]
|
Facility
|
OP
|
$8.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
3000295
|
|
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
|
|
|
LOPERAMIDE CAP [2 MG]
|
Facility
|
IP
|
$8.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
3000295
|
|
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
|
|
|
LORATADINE TAB [10 MG]
|
Facility
|
OP
|
$8.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
3000296
|
|
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
|
|
|
LORATADINE TAB [10 MG]
|
Facility
|
IP
|
$8.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
3000296
|
|
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
|
|
|
LORAZEPAM INJ [2 MG/ML] VL
|
Facility
|
OP
|
$14.00
|
|
|
Service Code
|
HCPCS J2060
|
| Hospital Charge Code |
3000297
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.80 |
| Max. Negotiated Rate |
$14.00 |
| Rate for Payer: Aetna Commercial |
$13.30
|
| Rate for Payer: Aetna Medicare |
$12.60
|
| Rate for Payer: BCBS MT CHIP |
$12.60
|
| Rate for Payer: BCBS MT Closed Plan Network |
$13.30
|
| Rate for Payer: BCBS MT HealthLink |
$12.60
|
| Rate for Payer: BCBS MT Medicare |
$12.60
|
| Rate for Payer: BCBS MT POS |
$13.30
|
| Rate for Payer: BCBS MT Traditional |
$14.00
|
| Rate for Payer: Cash Price |
$12.60
|
| Rate for Payer: Cigna Commercial |
$13.30
|
| Rate for Payer: Cigna Medicare |
$12.60
|
| Rate for Payer: Medicaid All Medicaid |
$12.88
|
| Rate for Payer: Medicare All Medicare |
$9.80
|
| Rate for Payer: Monida Allegiance |
$13.30
|
| Rate for Payer: Monida First Choice Health |
$13.58
|
| Rate for Payer: Monida Montana Health Co-op |
$13.30
|
| Rate for Payer: Monida PacificSource |
$13.30
|
|
