|
MAXORB ALGINATE DRESSING MSC94
|
Facility
|
OP
|
$21.00
|
|
| Hospital Charge Code |
80040067
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$14.70 |
| Max. Negotiated Rate |
$21.00 |
| Rate for Payer: Aetna Commercial |
$19.95
|
| Rate for Payer: Aetna Medicare |
$18.90
|
| Rate for Payer: BCBS MT CHIP |
$18.90
|
| Rate for Payer: BCBS MT Closed Plan Network |
$19.95
|
| Rate for Payer: BCBS MT HealthLink |
$18.90
|
| Rate for Payer: BCBS MT Medicare |
$18.90
|
| Rate for Payer: BCBS MT POS |
$19.95
|
| Rate for Payer: BCBS MT Traditional |
$21.00
|
| Rate for Payer: Cash Price |
$18.90
|
| Rate for Payer: Cigna Commercial |
$19.95
|
| Rate for Payer: Cigna Medicare |
$18.90
|
| Rate for Payer: Medicaid All Medicaid |
$19.32
|
| Rate for Payer: Medicare All Medicare |
$14.70
|
| Rate for Payer: Monida Allegiance |
$19.95
|
| Rate for Payer: Monida First Choice Health |
$20.37
|
| Rate for Payer: Monida Montana Health Co-op |
$19.95
|
| Rate for Payer: Monida PacificSource |
$19.95
|
|
|
MEASLES AB, IGG (096560)
|
Facility
|
IP
|
$29.00
|
|
|
Service Code
|
HCPCS 86765
|
| Hospital Charge Code |
4086765
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$20.30 |
| Max. Negotiated Rate |
$29.00 |
| Rate for Payer: Aetna Commercial |
$27.55
|
| Rate for Payer: Aetna Medicare |
$26.10
|
| Rate for Payer: BCBS MT CHIP |
$26.10
|
| Rate for Payer: BCBS MT Closed Plan Network |
$27.55
|
| Rate for Payer: BCBS MT HealthLink |
$26.10
|
| Rate for Payer: BCBS MT Medicare |
$26.10
|
| Rate for Payer: BCBS MT POS |
$27.55
|
| Rate for Payer: BCBS MT Traditional |
$29.00
|
| Rate for Payer: Cash Price |
$26.10
|
| Rate for Payer: Cigna Commercial |
$27.55
|
| Rate for Payer: Cigna Medicare |
$26.10
|
| Rate for Payer: Medicaid All Medicaid |
$26.68
|
| Rate for Payer: Medicare All Medicare |
$20.30
|
| Rate for Payer: Monida Allegiance |
$27.55
|
| Rate for Payer: Monida First Choice Health |
$28.13
|
| Rate for Payer: Monida Montana Health Co-op |
$27.55
|
| Rate for Payer: Monida PacificSource |
$27.55
|
|
|
MEASLES AB, IGG (096560)
|
Facility
|
OP
|
$29.00
|
|
|
Service Code
|
HCPCS 86765
|
| Hospital Charge Code |
4086765
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$20.30 |
| Max. Negotiated Rate |
$29.00 |
| Rate for Payer: Aetna Commercial |
$27.55
|
| Rate for Payer: Aetna Medicare |
$26.10
|
| Rate for Payer: BCBS MT CHIP |
$26.10
|
| Rate for Payer: BCBS MT Closed Plan Network |
$27.55
|
| Rate for Payer: BCBS MT HealthLink |
$26.10
|
| Rate for Payer: BCBS MT Medicare |
$26.10
|
| Rate for Payer: BCBS MT POS |
$27.55
|
| Rate for Payer: BCBS MT Traditional |
$29.00
|
| Rate for Payer: Cash Price |
$26.10
|
| Rate for Payer: Cigna Commercial |
$27.55
|
| Rate for Payer: Cigna Medicare |
$26.10
|
| Rate for Payer: Medicaid All Medicaid |
$26.68
|
| Rate for Payer: Medicare All Medicare |
$20.30
|
| Rate for Payer: Monida Allegiance |
$27.55
|
| Rate for Payer: Monida First Choice Health |
$28.13
|
| Rate for Payer: Monida Montana Health Co-op |
$27.55
|
| Rate for Payer: Monida PacificSource |
$27.55
|
|
|
MECLIZINE TAB [12.5 MG]
|
Facility
|
IP
|
$8.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
3000305
|
|
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
|
|
|
MECLIZINE TAB [12.5 MG]
|
Facility
|
OP
|
$8.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
3000305
|
|
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
|
|
|
MEDROXYPROGESTERONE ACETATE 150MG INJ
|
Facility
|
IP
|
$182.00
|
|
|
Service Code
|
NDC 67457088799
|
| Hospital Charge Code |
3007225
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$127.40 |
| Max. Negotiated Rate |
$182.00 |
| Rate for Payer: Aetna Commercial |
$172.90
|
| Rate for Payer: Aetna Medicare |
$163.80
|
| Rate for Payer: BCBS MT CHIP |
$163.80
|
| Rate for Payer: BCBS MT Closed Plan Network |
$172.90
|
| Rate for Payer: BCBS MT HealthLink |
$163.80
|
| Rate for Payer: BCBS MT Medicare |
$163.80
|
| Rate for Payer: BCBS MT POS |
$172.90
|
| Rate for Payer: BCBS MT Traditional |
$182.00
|
| Rate for Payer: Cash Price |
$163.80
|
| Rate for Payer: Cigna Commercial |
$172.90
|
| Rate for Payer: Cigna Medicare |
$163.80
|
| Rate for Payer: Medicaid All Medicaid |
$167.44
|
| Rate for Payer: Medicare All Medicare |
$127.40
|
| Rate for Payer: Monida Allegiance |
$172.90
|
| Rate for Payer: Monida First Choice Health |
$176.54
|
| Rate for Payer: Monida Montana Health Co-op |
$172.90
|
| Rate for Payer: Monida PacificSource |
$172.90
|
|
|
MEDROXYPROGESTERONE ACETATE 150MG INJ
|
Facility
|
OP
|
$182.00
|
|
|
Service Code
|
NDC 67457088799
|
| Hospital Charge Code |
3007225
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$127.40 |
| Max. Negotiated Rate |
$182.00 |
| Rate for Payer: Aetna Commercial |
$172.90
|
| Rate for Payer: Aetna Medicare |
$163.80
|
| Rate for Payer: BCBS MT CHIP |
$163.80
|
| Rate for Payer: BCBS MT Closed Plan Network |
$172.90
|
| Rate for Payer: BCBS MT HealthLink |
$163.80
|
| Rate for Payer: BCBS MT Medicare |
$163.80
|
| Rate for Payer: BCBS MT POS |
$172.90
|
| Rate for Payer: BCBS MT Traditional |
$182.00
|
| Rate for Payer: Cash Price |
$163.80
|
| Rate for Payer: Cigna Commercial |
$172.90
|
| Rate for Payer: Cigna Medicare |
$163.80
|
| Rate for Payer: Medicaid All Medicaid |
$167.44
|
| Rate for Payer: Medicare All Medicare |
$127.40
|
| Rate for Payer: Monida Allegiance |
$172.90
|
| Rate for Payer: Monida First Choice Health |
$176.54
|
| Rate for Payer: Monida Montana Health Co-op |
$172.90
|
| Rate for Payer: Monida PacificSource |
$172.90
|
|
|
MEGESTROL 40 MG TABLET-NF
|
Facility
|
IP
|
$8.00
|
|
|
Service Code
|
NDC 00555060702
|
| Hospital Charge Code |
3007208
|
|
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
|
|
|
MEGESTROL 40 MG TABLET-NF
|
Facility
|
OP
|
$8.00
|
|
|
Service Code
|
NDC 00555060702
|
| Hospital Charge Code |
3007208
|
|
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
|
|
|
MELATONIN TAB [3 MG]
|
Facility
|
OP
|
$8.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
3000306
|
|
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
|
|
|
MELATONIN TAB [3 MG]
|
Facility
|
IP
|
$8.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
3000306
|
|
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
|
|
|
MELOXICAM TAB [7.5 MG]
|
Facility
|
OP
|
$10.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
3007206
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.00 |
| Max. Negotiated Rate |
$10.00 |
| Rate for Payer: Aetna Commercial |
$9.50
|
| Rate for Payer: Aetna Medicare |
$9.00
|
| Rate for Payer: BCBS MT CHIP |
$9.00
|
| Rate for Payer: BCBS MT Closed Plan Network |
$9.50
|
| Rate for Payer: BCBS MT HealthLink |
$9.00
|
| Rate for Payer: BCBS MT Medicare |
$9.00
|
| Rate for Payer: BCBS MT POS |
$9.50
|
| Rate for Payer: BCBS MT Traditional |
$10.00
|
| Rate for Payer: Cash Price |
$9.00
|
| Rate for Payer: Cigna Commercial |
$9.50
|
| Rate for Payer: Cigna Medicare |
$9.00
|
| Rate for Payer: Medicaid All Medicaid |
$9.20
|
| Rate for Payer: Medicare All Medicare |
$7.00
|
| Rate for Payer: Monida Allegiance |
$9.50
|
| Rate for Payer: Monida First Choice Health |
$9.70
|
| Rate for Payer: Monida Montana Health Co-op |
$9.50
|
| Rate for Payer: Monida PacificSource |
$9.50
|
|
|
MELOXICAM TAB [7.5 MG]
|
Facility
|
IP
|
$10.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
3007206
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.00 |
| Max. Negotiated Rate |
$10.00 |
| Rate for Payer: Aetna Commercial |
$9.50
|
| Rate for Payer: Aetna Medicare |
$9.00
|
| Rate for Payer: BCBS MT CHIP |
$9.00
|
| Rate for Payer: BCBS MT Closed Plan Network |
$9.50
|
| Rate for Payer: BCBS MT HealthLink |
$9.00
|
| Rate for Payer: BCBS MT Medicare |
$9.00
|
| Rate for Payer: BCBS MT POS |
$9.50
|
| Rate for Payer: BCBS MT Traditional |
$10.00
|
| Rate for Payer: Cash Price |
$9.00
|
| Rate for Payer: Cigna Commercial |
$9.50
|
| Rate for Payer: Cigna Medicare |
$9.00
|
| Rate for Payer: Medicaid All Medicaid |
$9.20
|
| Rate for Payer: Medicare All Medicare |
$7.00
|
| Rate for Payer: Monida Allegiance |
$9.50
|
| Rate for Payer: Monida First Choice Health |
$9.70
|
| Rate for Payer: Monida Montana Health Co-op |
$9.50
|
| Rate for Payer: Monida PacificSource |
$9.50
|
|
|
MEMANTINE TAB [10 MG]
|
Facility
|
OP
|
$8.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
3000307
|
|
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
|
|
|
MEMANTINE TAB [10 MG]
|
Facility
|
IP
|
$8.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
3000307
|
|
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
|
|
|
MEROPENEM 1 GM INJECTION
|
Facility
|
OP
|
$76.80
|
|
|
Service Code
|
NDC 63323050830
|
| Hospital Charge Code |
3007273
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$53.76 |
| Max. Negotiated Rate |
$76.80 |
| Rate for Payer: Aetna Commercial |
$72.96
|
| Rate for Payer: Aetna Medicare |
$69.12
|
| Rate for Payer: BCBS MT CHIP |
$69.12
|
| Rate for Payer: BCBS MT Closed Plan Network |
$72.96
|
| Rate for Payer: BCBS MT HealthLink |
$69.12
|
| Rate for Payer: BCBS MT Medicare |
$69.12
|
| Rate for Payer: BCBS MT POS |
$72.96
|
| Rate for Payer: BCBS MT Traditional |
$76.80
|
| Rate for Payer: Cash Price |
$69.12
|
| Rate for Payer: Cigna Commercial |
$72.96
|
| Rate for Payer: Cigna Medicare |
$69.12
|
| Rate for Payer: Medicaid All Medicaid |
$70.66
|
| Rate for Payer: Medicare All Medicare |
$53.76
|
| Rate for Payer: Monida Allegiance |
$72.96
|
| Rate for Payer: Monida First Choice Health |
$74.50
|
| Rate for Payer: Monida Montana Health Co-op |
$72.96
|
| Rate for Payer: Monida PacificSource |
$72.96
|
|
|
MEROPENEM 1 GM INJECTION
|
Facility
|
IP
|
$76.80
|
|
|
Service Code
|
NDC 63323050830
|
| Hospital Charge Code |
3007273
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$53.76 |
| Max. Negotiated Rate |
$76.80 |
| Rate for Payer: Aetna Commercial |
$72.96
|
| Rate for Payer: Aetna Medicare |
$69.12
|
| Rate for Payer: BCBS MT CHIP |
$69.12
|
| Rate for Payer: BCBS MT Closed Plan Network |
$72.96
|
| Rate for Payer: BCBS MT HealthLink |
$69.12
|
| Rate for Payer: BCBS MT Medicare |
$69.12
|
| Rate for Payer: BCBS MT POS |
$72.96
|
| Rate for Payer: BCBS MT Traditional |
$76.80
|
| Rate for Payer: Cash Price |
$69.12
|
| Rate for Payer: Cigna Commercial |
$72.96
|
| Rate for Payer: Cigna Medicare |
$69.12
|
| Rate for Payer: Medicaid All Medicaid |
$70.66
|
| Rate for Payer: Medicare All Medicare |
$53.76
|
| Rate for Payer: Monida Allegiance |
$72.96
|
| Rate for Payer: Monida First Choice Health |
$74.50
|
| Rate for Payer: Monida Montana Health Co-op |
$72.96
|
| Rate for Payer: Monida PacificSource |
$72.96
|
|
|
MEROPENEM 500MG INJ
|
Facility
|
OP
|
$72.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
3000308
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$50.40 |
| Max. Negotiated Rate |
$72.00 |
| Rate for Payer: Aetna Commercial |
$68.40
|
| Rate for Payer: Aetna Medicare |
$64.80
|
| Rate for Payer: BCBS MT CHIP |
$64.80
|
| Rate for Payer: BCBS MT Closed Plan Network |
$68.40
|
| Rate for Payer: BCBS MT HealthLink |
$64.80
|
| Rate for Payer: BCBS MT Medicare |
$64.80
|
| Rate for Payer: BCBS MT POS |
$68.40
|
| Rate for Payer: BCBS MT Traditional |
$72.00
|
| Rate for Payer: Cash Price |
$64.80
|
| Rate for Payer: Cigna Commercial |
$68.40
|
| Rate for Payer: Cigna Medicare |
$64.80
|
| Rate for Payer: Medicaid All Medicaid |
$66.24
|
| Rate for Payer: Medicare All Medicare |
$50.40
|
| Rate for Payer: Monida Allegiance |
$68.40
|
| Rate for Payer: Monida First Choice Health |
$69.84
|
| Rate for Payer: Monida Montana Health Co-op |
$68.40
|
| Rate for Payer: Monida PacificSource |
$68.40
|
|
|
MEROPENEM 500MG INJ
|
Facility
|
IP
|
$72.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
3000308
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$50.40 |
| Max. Negotiated Rate |
$72.00 |
| Rate for Payer: Aetna Commercial |
$68.40
|
| Rate for Payer: Aetna Medicare |
$64.80
|
| Rate for Payer: BCBS MT CHIP |
$64.80
|
| Rate for Payer: BCBS MT Closed Plan Network |
$68.40
|
| Rate for Payer: BCBS MT HealthLink |
$64.80
|
| Rate for Payer: BCBS MT Medicare |
$64.80
|
| Rate for Payer: BCBS MT POS |
$68.40
|
| Rate for Payer: BCBS MT Traditional |
$72.00
|
| Rate for Payer: Cash Price |
$64.80
|
| Rate for Payer: Cigna Commercial |
$68.40
|
| Rate for Payer: Cigna Medicare |
$64.80
|
| Rate for Payer: Medicaid All Medicaid |
$66.24
|
| Rate for Payer: Medicare All Medicare |
$50.40
|
| Rate for Payer: Monida Allegiance |
$68.40
|
| Rate for Payer: Monida First Choice Health |
$69.84
|
| Rate for Payer: Monida Montana Health Co-op |
$68.40
|
| Rate for Payer: Monida PacificSource |
$68.40
|
|
|
MEROPENEM/NS IVPB : 1GM/50ML
|
Facility
|
IP
|
$79.55
|
|
|
Service Code
|
NDC 99999999999
|
| Hospital Charge Code |
3007276
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$55.68 |
| Max. Negotiated Rate |
$79.55 |
| Rate for Payer: Aetna Commercial |
$75.57
|
| Rate for Payer: Aetna Medicare |
$71.60
|
| Rate for Payer: BCBS MT CHIP |
$71.60
|
| Rate for Payer: BCBS MT Closed Plan Network |
$75.57
|
| Rate for Payer: BCBS MT HealthLink |
$71.60
|
| Rate for Payer: BCBS MT Medicare |
$71.60
|
| Rate for Payer: BCBS MT POS |
$75.57
|
| Rate for Payer: BCBS MT Traditional |
$79.55
|
| Rate for Payer: Cash Price |
$71.60
|
| Rate for Payer: Cigna Commercial |
$75.57
|
| Rate for Payer: Cigna Medicare |
$71.60
|
| Rate for Payer: Medicaid All Medicaid |
$73.19
|
| Rate for Payer: Medicare All Medicare |
$55.68
|
| Rate for Payer: Monida Allegiance |
$75.57
|
| Rate for Payer: Monida First Choice Health |
$77.16
|
| Rate for Payer: Monida Montana Health Co-op |
$75.57
|
| Rate for Payer: Monida PacificSource |
$75.57
|
|
|
MEROPENEM/NS IVPB : 1GM/50ML
|
Facility
|
OP
|
$79.55
|
|
|
Service Code
|
NDC 99999999999
|
| Hospital Charge Code |
3007276
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$55.68 |
| Max. Negotiated Rate |
$79.55 |
| Rate for Payer: Aetna Commercial |
$75.57
|
| Rate for Payer: Aetna Medicare |
$71.60
|
| Rate for Payer: BCBS MT CHIP |
$71.60
|
| Rate for Payer: BCBS MT Closed Plan Network |
$75.57
|
| Rate for Payer: BCBS MT HealthLink |
$71.60
|
| Rate for Payer: BCBS MT Medicare |
$71.60
|
| Rate for Payer: BCBS MT POS |
$75.57
|
| Rate for Payer: BCBS MT Traditional |
$79.55
|
| Rate for Payer: Cash Price |
$71.60
|
| Rate for Payer: Cigna Commercial |
$75.57
|
| Rate for Payer: Cigna Medicare |
$71.60
|
| Rate for Payer: Medicaid All Medicaid |
$73.19
|
| Rate for Payer: Medicare All Medicare |
$55.68
|
| Rate for Payer: Monida Allegiance |
$75.57
|
| Rate for Payer: Monida First Choice Health |
$77.16
|
| Rate for Payer: Monida Montana Health Co-op |
$75.57
|
| Rate for Payer: Monida PacificSource |
$75.57
|
|
|
MESALAMINE 0.375 GRAM CAPSULE-NF
|
Facility
|
OP
|
$14.75
|
|
|
Service Code
|
NDC 00378137578
|
| Hospital Charge Code |
3007345
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.32 |
| Max. Negotiated Rate |
$14.75 |
| Rate for Payer: Aetna Commercial |
$14.01
|
| Rate for Payer: Aetna Medicare |
$13.28
|
| Rate for Payer: BCBS MT CHIP |
$13.28
|
| Rate for Payer: BCBS MT Closed Plan Network |
$14.01
|
| Rate for Payer: BCBS MT HealthLink |
$13.28
|
| Rate for Payer: BCBS MT Medicare |
$13.28
|
| Rate for Payer: BCBS MT POS |
$14.01
|
| Rate for Payer: BCBS MT Traditional |
$14.75
|
| Rate for Payer: Cash Price |
$13.28
|
| Rate for Payer: Cigna Commercial |
$14.01
|
| Rate for Payer: Cigna Medicare |
$13.28
|
| Rate for Payer: Medicaid All Medicaid |
$13.57
|
| Rate for Payer: Medicare All Medicare |
$10.32
|
| Rate for Payer: Monida Allegiance |
$14.01
|
| Rate for Payer: Monida First Choice Health |
$14.31
|
| Rate for Payer: Monida Montana Health Co-op |
$14.01
|
| Rate for Payer: Monida PacificSource |
$14.01
|
|
|
MESALAMINE 0.375 GRAM CAPSULE-NF
|
Facility
|
IP
|
$14.75
|
|
|
Service Code
|
NDC 00378137578
|
| Hospital Charge Code |
3007345
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.32 |
| Max. Negotiated Rate |
$14.75 |
| Rate for Payer: Aetna Commercial |
$14.01
|
| Rate for Payer: Aetna Medicare |
$13.28
|
| Rate for Payer: BCBS MT CHIP |
$13.28
|
| Rate for Payer: BCBS MT Closed Plan Network |
$14.01
|
| Rate for Payer: BCBS MT HealthLink |
$13.28
|
| Rate for Payer: BCBS MT Medicare |
$13.28
|
| Rate for Payer: BCBS MT POS |
$14.01
|
| Rate for Payer: BCBS MT Traditional |
$14.75
|
| Rate for Payer: Cash Price |
$13.28
|
| Rate for Payer: Cigna Commercial |
$14.01
|
| Rate for Payer: Cigna Medicare |
$13.28
|
| Rate for Payer: Medicaid All Medicaid |
$13.57
|
| Rate for Payer: Medicare All Medicare |
$10.32
|
| Rate for Payer: Monida Allegiance |
$14.01
|
| Rate for Payer: Monida First Choice Health |
$14.31
|
| Rate for Payer: Monida Montana Health Co-op |
$14.01
|
| Rate for Payer: Monida PacificSource |
$14.01
|
|
|
METANEPHRINES, 24-HOUR, URINE (004234)
|
Facility
|
IP
|
$75.00
|
|
|
Service Code
|
HCPCS 83835
|
| Hospital Charge Code |
4000062
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$52.50 |
| Max. Negotiated Rate |
$75.00 |
| Rate for Payer: Aetna Commercial |
$71.25
|
| Rate for Payer: Aetna Medicare |
$67.50
|
| Rate for Payer: BCBS MT CHIP |
$67.50
|
| Rate for Payer: BCBS MT Closed Plan Network |
$71.25
|
| Rate for Payer: BCBS MT HealthLink |
$67.50
|
| Rate for Payer: BCBS MT Medicare |
$67.50
|
| Rate for Payer: BCBS MT POS |
$71.25
|
| Rate for Payer: BCBS MT Traditional |
$75.00
|
| Rate for Payer: Cash Price |
$67.50
|
| Rate for Payer: Cigna Commercial |
$71.25
|
| Rate for Payer: Cigna Medicare |
$67.50
|
| Rate for Payer: Medicaid All Medicaid |
$69.00
|
| Rate for Payer: Medicare All Medicare |
$52.50
|
| Rate for Payer: Monida Allegiance |
$71.25
|
| Rate for Payer: Monida First Choice Health |
$72.75
|
| Rate for Payer: Monida Montana Health Co-op |
$71.25
|
| Rate for Payer: Monida PacificSource |
$71.25
|
|
|
METANEPHRINES, 24-HOUR, URINE (004234)
|
Facility
|
OP
|
$75.00
|
|
|
Service Code
|
HCPCS 83835
|
| Hospital Charge Code |
4000062
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$52.50 |
| Max. Negotiated Rate |
$75.00 |
| Rate for Payer: Aetna Commercial |
$71.25
|
| Rate for Payer: Aetna Medicare |
$67.50
|
| Rate for Payer: BCBS MT CHIP |
$67.50
|
| Rate for Payer: BCBS MT Closed Plan Network |
$71.25
|
| Rate for Payer: BCBS MT HealthLink |
$67.50
|
| Rate for Payer: BCBS MT Medicare |
$67.50
|
| Rate for Payer: BCBS MT POS |
$71.25
|
| Rate for Payer: BCBS MT Traditional |
$75.00
|
| Rate for Payer: Cash Price |
$67.50
|
| Rate for Payer: Cigna Commercial |
$71.25
|
| Rate for Payer: Cigna Medicare |
$67.50
|
| Rate for Payer: Medicaid All Medicaid |
$69.00
|
| Rate for Payer: Medicare All Medicare |
$52.50
|
| Rate for Payer: Monida Allegiance |
$71.25
|
| Rate for Payer: Monida First Choice Health |
$72.75
|
| Rate for Payer: Monida Montana Health Co-op |
$71.25
|
| Rate for Payer: Monida PacificSource |
$71.25
|
|
