|
LEVEMIR 100U/ML 10ML VIAL-NF
|
Facility
|
OP
|
$702.60
|
|
|
Service Code
|
NDC 00169368712
|
| Hospital Charge Code |
3007249
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$491.82 |
| Max. Negotiated Rate |
$702.60 |
| Rate for Payer: Aetna Commercial |
$667.47
|
| Rate for Payer: Aetna Medicare |
$632.34
|
| Rate for Payer: BCBS MT CHIP |
$632.34
|
| Rate for Payer: BCBS MT Closed Plan Network |
$667.47
|
| Rate for Payer: BCBS MT HealthLink |
$632.34
|
| Rate for Payer: BCBS MT Medicare |
$632.34
|
| Rate for Payer: BCBS MT POS |
$667.47
|
| Rate for Payer: BCBS MT Traditional |
$702.60
|
| Rate for Payer: Cash Price |
$632.34
|
| Rate for Payer: Cigna Commercial |
$667.47
|
| Rate for Payer: Cigna Medicare |
$632.34
|
| Rate for Payer: Medicaid All Medicaid |
$646.39
|
| Rate for Payer: Medicare All Medicare |
$491.82
|
| Rate for Payer: Monida Allegiance |
$667.47
|
| Rate for Payer: Monida First Choice Health |
$681.52
|
| Rate for Payer: Monida Montana Health Co-op |
$667.47
|
| Rate for Payer: Monida PacificSource |
$667.47
|
|
|
LEVETIRACETAM 500MG TAB
|
Facility
|
OP
|
$8.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
3000270
|
|
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
|
|
|
LEVETIRACETAM 500MG TAB
|
Facility
|
IP
|
$8.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
3000270
|
|
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
|
|
|
LEVETIRACETAM (716936)
|
Facility
|
OP
|
$92.00
|
|
|
Service Code
|
HCPCS 80177
|
| Hospital Charge Code |
4080299
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$64.40 |
| Max. Negotiated Rate |
$92.00 |
| Rate for Payer: Aetna Commercial |
$87.40
|
| Rate for Payer: Aetna Medicare |
$82.80
|
| Rate for Payer: BCBS MT CHIP |
$82.80
|
| Rate for Payer: BCBS MT Closed Plan Network |
$87.40
|
| Rate for Payer: BCBS MT HealthLink |
$82.80
|
| Rate for Payer: BCBS MT Medicare |
$82.80
|
| Rate for Payer: BCBS MT POS |
$87.40
|
| Rate for Payer: BCBS MT Traditional |
$92.00
|
| Rate for Payer: Cash Price |
$82.80
|
| Rate for Payer: Cigna Commercial |
$87.40
|
| Rate for Payer: Cigna Medicare |
$82.80
|
| Rate for Payer: Medicaid All Medicaid |
$84.64
|
| Rate for Payer: Medicare All Medicare |
$64.40
|
| Rate for Payer: Monida Allegiance |
$87.40
|
| Rate for Payer: Monida First Choice Health |
$89.24
|
| Rate for Payer: Monida Montana Health Co-op |
$87.40
|
| Rate for Payer: Monida PacificSource |
$87.40
|
|
|
LEVETIRACETAM (716936)
|
Facility
|
IP
|
$92.00
|
|
|
Service Code
|
HCPCS 80177
|
| Hospital Charge Code |
4080299
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$64.40 |
| Max. Negotiated Rate |
$92.00 |
| Rate for Payer: Aetna Commercial |
$87.40
|
| Rate for Payer: Aetna Medicare |
$82.80
|
| Rate for Payer: BCBS MT CHIP |
$82.80
|
| Rate for Payer: BCBS MT Closed Plan Network |
$87.40
|
| Rate for Payer: BCBS MT HealthLink |
$82.80
|
| Rate for Payer: BCBS MT Medicare |
$82.80
|
| Rate for Payer: BCBS MT POS |
$87.40
|
| Rate for Payer: BCBS MT Traditional |
$92.00
|
| Rate for Payer: Cash Price |
$82.80
|
| Rate for Payer: Cigna Commercial |
$87.40
|
| Rate for Payer: Cigna Medicare |
$82.80
|
| Rate for Payer: Medicaid All Medicaid |
$84.64
|
| Rate for Payer: Medicare All Medicare |
$64.40
|
| Rate for Payer: Monida Allegiance |
$87.40
|
| Rate for Payer: Monida First Choice Health |
$89.24
|
| Rate for Payer: Monida Montana Health Co-op |
$87.40
|
| Rate for Payer: Monida PacificSource |
$87.40
|
|
|
LEVETIRACETAM INJ [500 MG/5 ML]
|
Facility
|
IP
|
$30.00
|
|
|
Service Code
|
HCPCS J1953
|
| Hospital Charge Code |
3000271
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$21.00 |
| Max. Negotiated Rate |
$30.00 |
| Rate for Payer: Aetna Commercial |
$28.50
|
| Rate for Payer: Aetna Medicare |
$27.00
|
| Rate for Payer: BCBS MT CHIP |
$27.00
|
| Rate for Payer: BCBS MT Closed Plan Network |
$28.50
|
| Rate for Payer: BCBS MT HealthLink |
$27.00
|
| Rate for Payer: BCBS MT Medicare |
$27.00
|
| Rate for Payer: BCBS MT POS |
$28.50
|
| Rate for Payer: BCBS MT Traditional |
$30.00
|
| Rate for Payer: Cash Price |
$27.00
|
| Rate for Payer: Cigna Commercial |
$28.50
|
| Rate for Payer: Cigna Medicare |
$27.00
|
| Rate for Payer: Medicaid All Medicaid |
$27.60
|
| Rate for Payer: Medicare All Medicare |
$21.00
|
| Rate for Payer: Monida Allegiance |
$28.50
|
| Rate for Payer: Monida First Choice Health |
$29.10
|
| Rate for Payer: Monida Montana Health Co-op |
$28.50
|
| Rate for Payer: Monida PacificSource |
$28.50
|
|
|
LEVETIRACETAM INJ [500 MG/5 ML]
|
Facility
|
OP
|
$30.00
|
|
|
Service Code
|
HCPCS J1953
|
| Hospital Charge Code |
3000271
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$21.00 |
| Max. Negotiated Rate |
$30.00 |
| Rate for Payer: Aetna Commercial |
$28.50
|
| Rate for Payer: Aetna Medicare |
$27.00
|
| Rate for Payer: BCBS MT CHIP |
$27.00
|
| Rate for Payer: BCBS MT Closed Plan Network |
$28.50
|
| Rate for Payer: BCBS MT HealthLink |
$27.00
|
| Rate for Payer: BCBS MT Medicare |
$27.00
|
| Rate for Payer: BCBS MT POS |
$28.50
|
| Rate for Payer: BCBS MT Traditional |
$30.00
|
| Rate for Payer: Cash Price |
$27.00
|
| Rate for Payer: Cigna Commercial |
$28.50
|
| Rate for Payer: Cigna Medicare |
$27.00
|
| Rate for Payer: Medicaid All Medicaid |
$27.60
|
| Rate for Payer: Medicare All Medicare |
$21.00
|
| Rate for Payer: Monida Allegiance |
$28.50
|
| Rate for Payer: Monida First Choice Health |
$29.10
|
| Rate for Payer: Monida Montana Health Co-op |
$28.50
|
| Rate for Payer: Monida PacificSource |
$28.50
|
|
|
LEVOFLOXACIN 250 MG IN D5W 50 ML NF
|
Facility
|
IP
|
$26.00
|
|
|
Service Code
|
NDC 36000004624
|
| Hospital Charge Code |
3007139
|
|
Hospital Revenue Code
|
258
|
| 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
|
|
|
LEVOFLOXACIN 250 MG IN D5W 50 ML NF
|
Facility
|
OP
|
$26.00
|
|
|
Service Code
|
NDC 36000004624
|
| Hospital Charge Code |
3007139
|
|
Hospital Revenue Code
|
258
|
| 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
|
|
|
LEVOFLOXACIN 500MG IN D5W 100ML PREMIX
|
Facility
|
OP
|
$26.00
|
|
|
Service Code
|
NDC 00143972101
|
| Hospital Charge Code |
3007140
|
|
Hospital Revenue Code
|
250
|
| 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
|
|
|
LEVOFLOXACIN 500MG IN D5W 100ML PREMIX
|
Facility
|
IP
|
$26.00
|
|
|
Service Code
|
NDC 00143972101
|
| Hospital Charge Code |
3007140
|
|
Hospital Revenue Code
|
250
|
| 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
|
|
|
LEVOFLOXACIN TAB [250 MG]
|
Facility
|
IP
|
$48.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
3000272
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$33.60 |
| Max. Negotiated Rate |
$48.00 |
| Rate for Payer: Aetna Commercial |
$45.60
|
| Rate for Payer: Aetna Medicare |
$43.20
|
| Rate for Payer: BCBS MT CHIP |
$43.20
|
| Rate for Payer: BCBS MT Closed Plan Network |
$45.60
|
| Rate for Payer: BCBS MT HealthLink |
$43.20
|
| Rate for Payer: BCBS MT Medicare |
$43.20
|
| Rate for Payer: BCBS MT POS |
$45.60
|
| Rate for Payer: BCBS MT Traditional |
$48.00
|
| Rate for Payer: Cash Price |
$43.20
|
| Rate for Payer: Cigna Commercial |
$45.60
|
| Rate for Payer: Cigna Medicare |
$43.20
|
| Rate for Payer: Medicaid All Medicaid |
$44.16
|
| Rate for Payer: Medicare All Medicare |
$33.60
|
| Rate for Payer: Monida Allegiance |
$45.60
|
| Rate for Payer: Monida First Choice Health |
$46.56
|
| Rate for Payer: Monida Montana Health Co-op |
$45.60
|
| Rate for Payer: Monida PacificSource |
$45.60
|
|
|
LEVOFLOXACIN TAB [250 MG]
|
Facility
|
OP
|
$48.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
3000272
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$33.60 |
| Max. Negotiated Rate |
$48.00 |
| Rate for Payer: Aetna Commercial |
$45.60
|
| Rate for Payer: Aetna Medicare |
$43.20
|
| Rate for Payer: BCBS MT CHIP |
$43.20
|
| Rate for Payer: BCBS MT Closed Plan Network |
$45.60
|
| Rate for Payer: BCBS MT HealthLink |
$43.20
|
| Rate for Payer: BCBS MT Medicare |
$43.20
|
| Rate for Payer: BCBS MT POS |
$45.60
|
| Rate for Payer: BCBS MT Traditional |
$48.00
|
| Rate for Payer: Cash Price |
$43.20
|
| Rate for Payer: Cigna Commercial |
$45.60
|
| Rate for Payer: Cigna Medicare |
$43.20
|
| Rate for Payer: Medicaid All Medicaid |
$44.16
|
| Rate for Payer: Medicare All Medicare |
$33.60
|
| Rate for Payer: Monida Allegiance |
$45.60
|
| Rate for Payer: Monida First Choice Health |
$46.56
|
| Rate for Payer: Monida Montana Health Co-op |
$45.60
|
| Rate for Payer: Monida PacificSource |
$45.60
|
|
|
LEVONORGESTREL [1.5 MG]
|
Facility
|
OP
|
$131.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
3000274
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$91.70 |
| Max. Negotiated Rate |
$131.00 |
| Rate for Payer: Aetna Commercial |
$124.45
|
| Rate for Payer: Aetna Medicare |
$117.90
|
| Rate for Payer: BCBS MT CHIP |
$117.90
|
| Rate for Payer: BCBS MT Closed Plan Network |
$124.45
|
| Rate for Payer: BCBS MT HealthLink |
$117.90
|
| Rate for Payer: BCBS MT Medicare |
$117.90
|
| Rate for Payer: BCBS MT POS |
$124.45
|
| Rate for Payer: BCBS MT Traditional |
$131.00
|
| Rate for Payer: Cash Price |
$117.90
|
| Rate for Payer: Cigna Commercial |
$124.45
|
| Rate for Payer: Cigna Medicare |
$117.90
|
| Rate for Payer: Medicaid All Medicaid |
$120.52
|
| Rate for Payer: Medicare All Medicare |
$91.70
|
| Rate for Payer: Monida Allegiance |
$124.45
|
| Rate for Payer: Monida First Choice Health |
$127.07
|
| Rate for Payer: Monida Montana Health Co-op |
$124.45
|
| Rate for Payer: Monida PacificSource |
$124.45
|
|
|
LEVONORGESTREL [1.5 MG]
|
Facility
|
IP
|
$131.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
3000274
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$91.70 |
| Max. Negotiated Rate |
$131.00 |
| Rate for Payer: Aetna Commercial |
$124.45
|
| Rate for Payer: Aetna Medicare |
$117.90
|
| Rate for Payer: BCBS MT CHIP |
$117.90
|
| Rate for Payer: BCBS MT Closed Plan Network |
$124.45
|
| Rate for Payer: BCBS MT HealthLink |
$117.90
|
| Rate for Payer: BCBS MT Medicare |
$117.90
|
| Rate for Payer: BCBS MT POS |
$124.45
|
| Rate for Payer: BCBS MT Traditional |
$131.00
|
| Rate for Payer: Cash Price |
$117.90
|
| Rate for Payer: Cigna Commercial |
$124.45
|
| Rate for Payer: Cigna Medicare |
$117.90
|
| Rate for Payer: Medicaid All Medicaid |
$120.52
|
| Rate for Payer: Medicare All Medicare |
$91.70
|
| Rate for Payer: Monida Allegiance |
$124.45
|
| Rate for Payer: Monida First Choice Health |
$127.07
|
| Rate for Payer: Monida Montana Health Co-op |
$124.45
|
| Rate for Payer: Monida PacificSource |
$124.45
|
|
|
LEVOTHYROXINE [137 MCG] TAB
|
Facility
|
OP
|
$8.00
|
|
|
Service Code
|
NDC 00527328746
|
| Hospital Charge Code |
3007147
|
|
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
|
|
|
LEVOTHYROXINE [137 MCG] TAB
|
Facility
|
IP
|
$8.00
|
|
|
Service Code
|
NDC 00527328746
|
| Hospital Charge Code |
3007147
|
|
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
|
|
|
LEVOTHYROXINE TAB [100 MCG]
|
Facility
|
OP
|
$8.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
3000275
|
|
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
|
|
|
LEVOTHYROXINE TAB [100 MCG]
|
Facility
|
IP
|
$8.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
3000275
|
|
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
|
|
|
LEVOTHYROXINE TAB [112 MCG]
|
Facility
|
IP
|
$8.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
3000276
|
|
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
|
|
|
LEVOTHYROXINE TAB [112 MCG]
|
Facility
|
OP
|
$8.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
3000276
|
|
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
|
|
|
LEVOTHYROXINE TAB [50 MCG]
|
Facility
|
IP
|
$8.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
3000277
|
|
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
|
|
|
LEVOTHYROXINE TAB [50 MCG]
|
Facility
|
OP
|
$8.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
3000277
|
|
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
|
|
|
LEVOTHYROXINE TAB [75 MCG]
|
Facility
|
IP
|
$8.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
3000278
|
|
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
|
|
|
LEVOTHYROXINE TAB [75 MCG]
|
Facility
|
OP
|
$8.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
3000278
|
|
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
|
|
