|
LITHIUM (007708)
|
Facility
|
OP
|
$60.00
|
|
|
Service Code
|
HCPCS 80178
|
| Hospital Charge Code |
4080178
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$42.00 |
| Max. Negotiated Rate |
$60.00 |
| Rate for Payer: Aetna Commercial |
$57.00
|
| Rate for Payer: Aetna Medicare |
$54.00
|
| Rate for Payer: BCBS MT CHIP |
$54.00
|
| Rate for Payer: BCBS MT Closed Plan Network |
$57.00
|
| Rate for Payer: BCBS MT HealthLink |
$54.00
|
| Rate for Payer: BCBS MT Medicare |
$54.00
|
| Rate for Payer: BCBS MT POS |
$57.00
|
| Rate for Payer: BCBS MT Traditional |
$60.00
|
| Rate for Payer: Cash Price |
$54.00
|
| Rate for Payer: Cigna Commercial |
$57.00
|
| Rate for Payer: Cigna Medicare |
$54.00
|
| Rate for Payer: Medicaid All Medicaid |
$55.20
|
| Rate for Payer: Medicare All Medicare |
$42.00
|
| Rate for Payer: Monida Allegiance |
$57.00
|
| Rate for Payer: Monida First Choice Health |
$58.20
|
| Rate for Payer: Monida Montana Health Co-op |
$57.00
|
| Rate for Payer: Monida PacificSource |
$57.00
|
|
|
LITHIUM (007708)
|
Facility
|
IP
|
$60.00
|
|
|
Service Code
|
HCPCS 80178
|
| Hospital Charge Code |
4080178
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$42.00 |
| Max. Negotiated Rate |
$60.00 |
| Rate for Payer: Aetna Commercial |
$57.00
|
| Rate for Payer: Aetna Medicare |
$54.00
|
| Rate for Payer: BCBS MT CHIP |
$54.00
|
| Rate for Payer: BCBS MT Closed Plan Network |
$57.00
|
| Rate for Payer: BCBS MT HealthLink |
$54.00
|
| Rate for Payer: BCBS MT Medicare |
$54.00
|
| Rate for Payer: BCBS MT POS |
$57.00
|
| Rate for Payer: BCBS MT Traditional |
$60.00
|
| Rate for Payer: Cash Price |
$54.00
|
| Rate for Payer: Cigna Commercial |
$57.00
|
| Rate for Payer: Cigna Medicare |
$54.00
|
| Rate for Payer: Medicaid All Medicaid |
$55.20
|
| Rate for Payer: Medicare All Medicare |
$42.00
|
| Rate for Payer: Monida Allegiance |
$57.00
|
| Rate for Payer: Monida First Choice Health |
$58.20
|
| Rate for Payer: Monida Montana Health Co-op |
$57.00
|
| Rate for Payer: Monida PacificSource |
$57.00
|
|
|
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 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-KIDNEY MICROSOMAL AB (006676)
|
Facility
|
IP
|
$71.00
|
|
|
Service Code
|
HCPCS 86376
|
| Hospital Charge Code |
4063761
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$49.70 |
| Max. Negotiated Rate |
$71.00 |
| Rate for Payer: Aetna Commercial |
$67.45
|
| Rate for Payer: Aetna Medicare |
$63.90
|
| Rate for Payer: BCBS MT CHIP |
$63.90
|
| Rate for Payer: BCBS MT Closed Plan Network |
$67.45
|
| Rate for Payer: BCBS MT HealthLink |
$63.90
|
| Rate for Payer: BCBS MT Medicare |
$63.90
|
| Rate for Payer: BCBS MT POS |
$67.45
|
| Rate for Payer: BCBS MT Traditional |
$71.00
|
| Rate for Payer: Cash Price |
$63.90
|
| Rate for Payer: Cigna Commercial |
$67.45
|
| Rate for Payer: Cigna Medicare |
$63.90
|
| Rate for Payer: Medicaid All Medicaid |
$65.32
|
| Rate for Payer: Medicare All Medicare |
$49.70
|
| Rate for Payer: Monida Allegiance |
$67.45
|
| Rate for Payer: Monida First Choice Health |
$68.87
|
| Rate for Payer: Monida Montana Health Co-op |
$67.45
|
| Rate for Payer: Monida PacificSource |
$67.45
|
|
|
LIVER-KIDNEY MICROSOMAL AB (006676)
|
Facility
|
OP
|
$71.00
|
|
|
Service Code
|
HCPCS 86376
|
| Hospital Charge Code |
4063761
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$49.70 |
| Max. Negotiated Rate |
$71.00 |
| Rate for Payer: Aetna Commercial |
$67.45
|
| Rate for Payer: Aetna Medicare |
$63.90
|
| Rate for Payer: BCBS MT CHIP |
$63.90
|
| Rate for Payer: BCBS MT Closed Plan Network |
$67.45
|
| Rate for Payer: BCBS MT HealthLink |
$63.90
|
| Rate for Payer: BCBS MT Medicare |
$63.90
|
| Rate for Payer: BCBS MT POS |
$67.45
|
| Rate for Payer: BCBS MT Traditional |
$71.00
|
| Rate for Payer: Cash Price |
$63.90
|
| Rate for Payer: Cigna Commercial |
$67.45
|
| Rate for Payer: Cigna Medicare |
$63.90
|
| Rate for Payer: Medicaid All Medicaid |
$65.32
|
| Rate for Payer: Medicare All Medicare |
$49.70
|
| Rate for Payer: Monida Allegiance |
$67.45
|
| Rate for Payer: Monida First Choice Health |
$68.87
|
| Rate for Payer: Monida Montana Health Co-op |
$67.45
|
| Rate for Payer: Monida PacificSource |
$67.45
|
|
|
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
|
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
|
|
|
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
|
|
|
LORAZEPAM INJ [2 MG/ML]
|
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
|
|
|
LORAZEPAM INJ [2 MG/ML]
|
Facility
|
IP
|
$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
|
|
|
LORAZEPAM ORAL SLN [2 MG/ML] 30ML NF
|
Facility
|
OP
|
$154.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
3000560
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$107.80 |
| Max. Negotiated Rate |
$154.00 |
| Rate for Payer: Aetna Commercial |
$146.30
|
| Rate for Payer: Aetna Medicare |
$138.60
|
| Rate for Payer: BCBS MT CHIP |
$138.60
|
| Rate for Payer: BCBS MT Closed Plan Network |
$146.30
|
| Rate for Payer: BCBS MT HealthLink |
$138.60
|
| Rate for Payer: BCBS MT Medicare |
$138.60
|
| Rate for Payer: BCBS MT POS |
$146.30
|
| Rate for Payer: BCBS MT Traditional |
$154.00
|
| Rate for Payer: Cash Price |
$138.60
|
| Rate for Payer: Cigna Commercial |
$146.30
|
| Rate for Payer: Cigna Medicare |
$138.60
|
| Rate for Payer: Medicaid All Medicaid |
$141.68
|
| Rate for Payer: Medicare All Medicare |
$107.80
|
| Rate for Payer: Monida Allegiance |
$146.30
|
| Rate for Payer: Monida First Choice Health |
$149.38
|
| Rate for Payer: Monida Montana Health Co-op |
$146.30
|
| Rate for Payer: Monida PacificSource |
$146.30
|
|
|
LORAZEPAM ORAL SLN [2 MG/ML] 30ML NF
|
Facility
|
IP
|
$154.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
3000560
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$107.80 |
| Max. Negotiated Rate |
$154.00 |
| Rate for Payer: Aetna Commercial |
$146.30
|
| Rate for Payer: Aetna Medicare |
$138.60
|
| Rate for Payer: BCBS MT CHIP |
$138.60
|
| Rate for Payer: BCBS MT Closed Plan Network |
$146.30
|
| Rate for Payer: BCBS MT HealthLink |
$138.60
|
| Rate for Payer: BCBS MT Medicare |
$138.60
|
| Rate for Payer: BCBS MT POS |
$146.30
|
| Rate for Payer: BCBS MT Traditional |
$154.00
|
| Rate for Payer: Cash Price |
$138.60
|
| Rate for Payer: Cigna Commercial |
$146.30
|
| Rate for Payer: Cigna Medicare |
$138.60
|
| Rate for Payer: Medicaid All Medicaid |
$141.68
|
| Rate for Payer: Medicare All Medicare |
$107.80
|
| Rate for Payer: Monida Allegiance |
$146.30
|
| Rate for Payer: Monida First Choice Health |
$149.38
|
| Rate for Payer: Monida Montana Health Co-op |
$146.30
|
| Rate for Payer: Monida PacificSource |
$146.30
|
|
|
LORAZEPAM TAB [0.5 MG]
|
Facility
|
IP
|
$8.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
3000298
|
|
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 TAB [0.5 MG]
|
Facility
|
OP
|
$8.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
3000298
|
|
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 TAB [2 MG] NF
|
Facility
|
IP
|
$8.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
3000501
|
|
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 TAB [2 MG] NF
|
Facility
|
OP
|
$8.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
3000501
|
|
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
|
|
|
LOSARTAN TAB [25 MG]
|
Facility
|
OP
|
$8.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
3000299
|
|
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
|
|
|
LOSARTAN TAB [25 MG]
|
Facility
|
IP
|
$8.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
3000299
|
|
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
|
|
|
LOVASTATIN TAB [10 MG] NF
|
Facility
|
OP
|
$8.00
|
|
|
Service Code
|
NDC 68001031400
|
| Hospital Charge Code |
3007391
|
|
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
|
|
|
LOVASTATIN TAB [10 MG] NF
|
Facility
|
IP
|
$8.00
|
|
|
Service Code
|
NDC 68001031400
|
| Hospital Charge Code |
3007391
|
|
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
|
|
|
LUBRICATING EYE DROPS 10ML BOTTLE
|
Facility
|
IP
|
$42.00
|
|
|
Service Code
|
NDC 00023663010
|
| Hospital Charge Code |
3007234
|
|
Hospital Revenue Code
|
250
|
| 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
|
|
|
LUBRICATING EYE DROPS 10ML BOTTLE
|
Facility
|
OP
|
$42.00
|
|
|
Service Code
|
NDC 00023663010
|
| Hospital Charge Code |
3007234
|
|
Hospital Revenue Code
|
250
|
| 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
|
|
|
LUPUS ANTICOAGULANT PROFILE (117054)
|
Facility
|
IP
|
$355.00
|
|
| Hospital Charge Code |
4056130
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$248.50 |
| Max. Negotiated Rate |
$355.00 |
| Rate for Payer: Aetna Commercial |
$337.25
|
| Rate for Payer: Aetna Medicare |
$319.50
|
| Rate for Payer: BCBS MT CHIP |
$319.50
|
| Rate for Payer: BCBS MT Closed Plan Network |
$337.25
|
| Rate for Payer: BCBS MT HealthLink |
$319.50
|
| Rate for Payer: BCBS MT Medicare |
$319.50
|
| Rate for Payer: BCBS MT POS |
$337.25
|
| Rate for Payer: BCBS MT Traditional |
$355.00
|
| Rate for Payer: Cash Price |
$319.50
|
| Rate for Payer: Cigna Commercial |
$337.25
|
| Rate for Payer: Cigna Medicare |
$319.50
|
| Rate for Payer: Medicaid All Medicaid |
$326.60
|
| Rate for Payer: Medicare All Medicare |
$248.50
|
| Rate for Payer: Monida Allegiance |
$337.25
|
| Rate for Payer: Monida First Choice Health |
$344.35
|
| Rate for Payer: Monida Montana Health Co-op |
$337.25
|
| Rate for Payer: Monida PacificSource |
$337.25
|
|
