|
PRO FEE STRAPPING OF HAND/FINGER
|
Professional
|
Both
|
$32.00
|
|
|
Service Code
|
HCPCS 29280
|
| Hospital Charge Code |
729280
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$22.40 |
| Max. Negotiated Rate |
$32.00 |
| Rate for Payer: Aetna Commercial |
$30.40
|
| Rate for Payer: Aetna Medicare |
$28.80
|
| Rate for Payer: BCBS MT CHIP |
$28.80
|
| Rate for Payer: BCBS MT Closed Plan Network |
$30.40
|
| Rate for Payer: BCBS MT HealthLink |
$28.80
|
| Rate for Payer: BCBS MT Medicare |
$28.80
|
| Rate for Payer: BCBS MT POS |
$30.40
|
| Rate for Payer: BCBS MT Traditional |
$32.00
|
| Rate for Payer: Cash Price |
$28.80
|
| Rate for Payer: Cigna Commercial |
$30.40
|
| Rate for Payer: Cigna Medicare |
$28.80
|
| Rate for Payer: Medicaid All Medicaid |
$29.44
|
| Rate for Payer: Medicare All Medicare |
$22.40
|
| Rate for Payer: Monida Allegiance |
$30.40
|
| Rate for Payer: Monida First Choice Health |
$31.04
|
| Rate for Payer: Monida Montana Health Co-op |
$30.40
|
| Rate for Payer: Monida PacificSource |
$30.40
|
|
|
PRO FEE TRIGGER POINT INJ 3+ 20553
|
Professional
|
Both
|
$132.00
|
|
|
Service Code
|
HCPCS 20553
|
| Hospital Charge Code |
720553
|
|
Hospital Revenue Code
|
964
|
| Min. Negotiated Rate |
$92.40 |
| Max. Negotiated Rate |
$132.00 |
| Rate for Payer: Aetna Commercial |
$125.40
|
| Rate for Payer: Aetna Medicare |
$118.80
|
| Rate for Payer: BCBS MT CHIP |
$118.80
|
| Rate for Payer: BCBS MT Closed Plan Network |
$125.40
|
| Rate for Payer: BCBS MT HealthLink |
$118.80
|
| Rate for Payer: BCBS MT Medicare |
$118.80
|
| Rate for Payer: BCBS MT POS |
$125.40
|
| Rate for Payer: BCBS MT Traditional |
$132.00
|
| Rate for Payer: Cash Price |
$118.80
|
| Rate for Payer: Cigna Commercial |
$125.40
|
| Rate for Payer: Cigna Medicare |
$118.80
|
| Rate for Payer: Medicaid All Medicaid |
$121.44
|
| Rate for Payer: Medicare All Medicare |
$92.40
|
| Rate for Payer: Monida Allegiance |
$125.40
|
| Rate for Payer: Monida First Choice Health |
$128.04
|
| Rate for Payer: Monida Montana Health Co-op |
$125.40
|
| Rate for Payer: Monida PacificSource |
$125.40
|
|
|
PRO FEE TRIG PT INJ 1-2 GRPS 20552(SIJ)
|
Professional
|
Both
|
$132.00
|
|
|
Service Code
|
HCPCS 20552
|
| Hospital Charge Code |
720552
|
|
Hospital Revenue Code
|
964
|
| Min. Negotiated Rate |
$92.40 |
| Max. Negotiated Rate |
$132.00 |
| Rate for Payer: Aetna Commercial |
$125.40
|
| Rate for Payer: Aetna Medicare |
$118.80
|
| Rate for Payer: BCBS MT CHIP |
$118.80
|
| Rate for Payer: BCBS MT Closed Plan Network |
$125.40
|
| Rate for Payer: BCBS MT HealthLink |
$118.80
|
| Rate for Payer: BCBS MT Medicare |
$118.80
|
| Rate for Payer: BCBS MT POS |
$125.40
|
| Rate for Payer: BCBS MT Traditional |
$132.00
|
| Rate for Payer: Cash Price |
$118.80
|
| Rate for Payer: Cigna Commercial |
$125.40
|
| Rate for Payer: Cigna Medicare |
$118.80
|
| Rate for Payer: Medicaid All Medicaid |
$121.44
|
| Rate for Payer: Medicare All Medicare |
$92.40
|
| Rate for Payer: Monida Allegiance |
$125.40
|
| Rate for Payer: Monida First Choice Health |
$128.04
|
| Rate for Payer: Monida Montana Health Co-op |
$125.40
|
| Rate for Payer: Monida PacificSource |
$125.40
|
|
|
PROGESTERONE (004317)
|
Facility
|
IP
|
$32.00
|
|
|
Service Code
|
HCPCS 84144
|
| Hospital Charge Code |
4084144
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$22.40 |
| Max. Negotiated Rate |
$32.00 |
| Rate for Payer: Aetna Commercial |
$30.40
|
| Rate for Payer: Aetna Medicare |
$28.80
|
| Rate for Payer: BCBS MT CHIP |
$28.80
|
| Rate for Payer: BCBS MT Closed Plan Network |
$30.40
|
| Rate for Payer: BCBS MT HealthLink |
$28.80
|
| Rate for Payer: BCBS MT Medicare |
$28.80
|
| Rate for Payer: BCBS MT POS |
$30.40
|
| Rate for Payer: BCBS MT Traditional |
$32.00
|
| Rate for Payer: Cash Price |
$28.80
|
| Rate for Payer: Cigna Commercial |
$30.40
|
| Rate for Payer: Cigna Medicare |
$28.80
|
| Rate for Payer: Medicaid All Medicaid |
$29.44
|
| Rate for Payer: Medicare All Medicare |
$22.40
|
| Rate for Payer: Monida Allegiance |
$30.40
|
| Rate for Payer: Monida First Choice Health |
$31.04
|
| Rate for Payer: Monida Montana Health Co-op |
$30.40
|
| Rate for Payer: Monida PacificSource |
$30.40
|
|
|
PROGESTERONE (004317)
|
Facility
|
OP
|
$32.00
|
|
|
Service Code
|
HCPCS 84144
|
| Hospital Charge Code |
4084144
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$22.40 |
| Max. Negotiated Rate |
$32.00 |
| Rate for Payer: Aetna Commercial |
$30.40
|
| Rate for Payer: Aetna Medicare |
$28.80
|
| Rate for Payer: BCBS MT CHIP |
$28.80
|
| Rate for Payer: BCBS MT Closed Plan Network |
$30.40
|
| Rate for Payer: BCBS MT HealthLink |
$28.80
|
| Rate for Payer: BCBS MT Medicare |
$28.80
|
| Rate for Payer: BCBS MT POS |
$30.40
|
| Rate for Payer: BCBS MT Traditional |
$32.00
|
| Rate for Payer: Cash Price |
$28.80
|
| Rate for Payer: Cigna Commercial |
$30.40
|
| Rate for Payer: Cigna Medicare |
$28.80
|
| Rate for Payer: Medicaid All Medicaid |
$29.44
|
| Rate for Payer: Medicare All Medicare |
$22.40
|
| Rate for Payer: Monida Allegiance |
$30.40
|
| Rate for Payer: Monida First Choice Health |
$31.04
|
| Rate for Payer: Monida Montana Health Co-op |
$30.40
|
| Rate for Payer: Monida PacificSource |
$30.40
|
|
|
PROLACTIN (004465)
|
Facility
|
OP
|
$33.00
|
|
|
Service Code
|
HCPCS 84146
|
| Hospital Charge Code |
4084146
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$23.10 |
| Max. Negotiated Rate |
$33.00 |
| Rate for Payer: Aetna Commercial |
$31.35
|
| Rate for Payer: Aetna Medicare |
$29.70
|
| Rate for Payer: BCBS MT CHIP |
$29.70
|
| Rate for Payer: BCBS MT Closed Plan Network |
$31.35
|
| Rate for Payer: BCBS MT HealthLink |
$29.70
|
| Rate for Payer: BCBS MT Medicare |
$29.70
|
| Rate for Payer: BCBS MT POS |
$31.35
|
| Rate for Payer: BCBS MT Traditional |
$33.00
|
| Rate for Payer: Cash Price |
$29.70
|
| Rate for Payer: Cigna Commercial |
$31.35
|
| Rate for Payer: Cigna Medicare |
$29.70
|
| Rate for Payer: Medicaid All Medicaid |
$30.36
|
| Rate for Payer: Medicare All Medicare |
$23.10
|
| Rate for Payer: Monida Allegiance |
$31.35
|
| Rate for Payer: Monida First Choice Health |
$32.01
|
| Rate for Payer: Monida Montana Health Co-op |
$31.35
|
| Rate for Payer: Monida PacificSource |
$31.35
|
|
|
PROLACTIN (004465)
|
Facility
|
IP
|
$33.00
|
|
|
Service Code
|
HCPCS 84146
|
| Hospital Charge Code |
4084146
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$23.10 |
| Max. Negotiated Rate |
$33.00 |
| Rate for Payer: Aetna Commercial |
$31.35
|
| Rate for Payer: Aetna Medicare |
$29.70
|
| Rate for Payer: BCBS MT CHIP |
$29.70
|
| Rate for Payer: BCBS MT Closed Plan Network |
$31.35
|
| Rate for Payer: BCBS MT HealthLink |
$29.70
|
| Rate for Payer: BCBS MT Medicare |
$29.70
|
| Rate for Payer: BCBS MT POS |
$31.35
|
| Rate for Payer: BCBS MT Traditional |
$33.00
|
| Rate for Payer: Cash Price |
$29.70
|
| Rate for Payer: Cigna Commercial |
$31.35
|
| Rate for Payer: Cigna Medicare |
$29.70
|
| Rate for Payer: Medicaid All Medicaid |
$30.36
|
| Rate for Payer: Medicare All Medicare |
$23.10
|
| Rate for Payer: Monida Allegiance |
$31.35
|
| Rate for Payer: Monida First Choice Health |
$32.01
|
| Rate for Payer: Monida Montana Health Co-op |
$31.35
|
| Rate for Payer: Monida PacificSource |
$31.35
|
|
|
PROMETHAZINE 25 MG TABLET
|
Facility
|
OP
|
$8.00
|
|
|
Service Code
|
NDC 68084015501
|
| Hospital Charge Code |
3007332
|
|
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
|
|
|
PROMETHAZINE 25 MG TABLET
|
Facility
|
IP
|
$8.00
|
|
|
Service Code
|
NDC 68084015501
|
| Hospital Charge Code |
3007332
|
|
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
|
|
|
PROMETHAZINE INJ [25 MG/ML]
|
Facility
|
IP
|
$8.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
3000562
|
|
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
|
|
|
PROMETHAZINE INJ [25 MG/ML]
|
Facility
|
OP
|
$8.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
3000562
|
|
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
|
|
|
PROMETHAZINE INJ [25 MG/ML]
|
Facility
|
IP
|
$8.00
|
|
|
Service Code
|
HCPCS J2550
|
| Hospital Charge Code |
3000405
|
|
Hospital Revenue Code
|
636
|
| 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
|
|
|
PROMETHAZINE INJ [25 MG/ML]
|
Facility
|
OP
|
$8.00
|
|
|
Service Code
|
HCPCS J2550
|
| Hospital Charge Code |
3000405
|
|
Hospital Revenue Code
|
636
|
| 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
|
|
|
PROMETHAZINE SUPPOSITORY 12.5MG
|
Facility
|
OP
|
$56.70
|
|
|
Service Code
|
NDC 00713053612
|
| Hospital Charge Code |
3007329
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$39.69 |
| Max. Negotiated Rate |
$56.70 |
| Rate for Payer: Aetna Commercial |
$53.86
|
| Rate for Payer: Aetna Medicare |
$51.03
|
| Rate for Payer: BCBS MT CHIP |
$51.03
|
| Rate for Payer: BCBS MT Closed Plan Network |
$53.86
|
| Rate for Payer: BCBS MT HealthLink |
$51.03
|
| Rate for Payer: BCBS MT Medicare |
$51.03
|
| Rate for Payer: BCBS MT POS |
$53.86
|
| Rate for Payer: BCBS MT Traditional |
$56.70
|
| Rate for Payer: Cash Price |
$51.03
|
| Rate for Payer: Cigna Commercial |
$53.86
|
| Rate for Payer: Cigna Medicare |
$51.03
|
| Rate for Payer: Medicaid All Medicaid |
$52.16
|
| Rate for Payer: Medicare All Medicare |
$39.69
|
| Rate for Payer: Monida Allegiance |
$53.86
|
| Rate for Payer: Monida First Choice Health |
$55.00
|
| Rate for Payer: Monida Montana Health Co-op |
$53.86
|
| Rate for Payer: Monida PacificSource |
$53.86
|
|
|
PROMETHAZINE SUPPOSITORY 12.5MG
|
Facility
|
IP
|
$56.70
|
|
|
Service Code
|
NDC 00713053612
|
| Hospital Charge Code |
3007329
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$39.69 |
| Max. Negotiated Rate |
$56.70 |
| Rate for Payer: Aetna Commercial |
$53.86
|
| Rate for Payer: Aetna Medicare |
$51.03
|
| Rate for Payer: BCBS MT CHIP |
$51.03
|
| Rate for Payer: BCBS MT Closed Plan Network |
$53.86
|
| Rate for Payer: BCBS MT HealthLink |
$51.03
|
| Rate for Payer: BCBS MT Medicare |
$51.03
|
| Rate for Payer: BCBS MT POS |
$53.86
|
| Rate for Payer: BCBS MT Traditional |
$56.70
|
| Rate for Payer: Cash Price |
$51.03
|
| Rate for Payer: Cigna Commercial |
$53.86
|
| Rate for Payer: Cigna Medicare |
$51.03
|
| Rate for Payer: Medicaid All Medicaid |
$52.16
|
| Rate for Payer: Medicare All Medicare |
$39.69
|
| Rate for Payer: Monida Allegiance |
$53.86
|
| Rate for Payer: Monida First Choice Health |
$55.00
|
| Rate for Payer: Monida Montana Health Co-op |
$53.86
|
| Rate for Payer: Monida PacificSource |
$53.86
|
|
|
PROMETHAZINE TAB [25 MG]
|
Facility
|
IP
|
$8.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
3000406
|
|
Hospital Revenue Code
|
259
|
| 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
|
|
|
PROMETHAZINE TAB [25 MG]
|
Facility
|
OP
|
$8.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
3000406
|
|
Hospital Revenue Code
|
259
|
| 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
|
|
|
PROPAFENONE 150MG TABLET-NF
|
Facility
|
OP
|
$8.00
|
|
|
Service Code
|
NDC 60687070901
|
| Hospital Charge Code |
3007297
|
|
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
|
|
|
PROPAFENONE 150MG TABLET-NF
|
Facility
|
IP
|
$8.00
|
|
|
Service Code
|
NDC 60687070901
|
| Hospital Charge Code |
3007297
|
|
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
|
|
|
PROPOFOL INJ [10 MG/ML] 20ML
|
Facility
|
OP
|
$24.00
|
|
|
Service Code
|
HCPCS J2704
|
| Hospital Charge Code |
3000563
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$16.80 |
| Max. Negotiated Rate |
$24.00 |
| Rate for Payer: Aetna Commercial |
$22.80
|
| Rate for Payer: Aetna Medicare |
$21.60
|
| Rate for Payer: BCBS MT CHIP |
$21.60
|
| Rate for Payer: BCBS MT Closed Plan Network |
$22.80
|
| Rate for Payer: BCBS MT HealthLink |
$21.60
|
| Rate for Payer: BCBS MT Medicare |
$21.60
|
| Rate for Payer: BCBS MT POS |
$22.80
|
| Rate for Payer: BCBS MT Traditional |
$24.00
|
| Rate for Payer: Cash Price |
$21.60
|
| Rate for Payer: Cigna Commercial |
$22.80
|
| Rate for Payer: Cigna Medicare |
$21.60
|
| Rate for Payer: Medicaid All Medicaid |
$22.08
|
| Rate for Payer: Medicare All Medicare |
$16.80
|
| Rate for Payer: Monida Allegiance |
$22.80
|
| Rate for Payer: Monida First Choice Health |
$23.28
|
| Rate for Payer: Monida Montana Health Co-op |
$22.80
|
| Rate for Payer: Monida PacificSource |
$22.80
|
|
|
PROPOFOL INJ [10 MG/ML] 20ML
|
Facility
|
IP
|
$24.00
|
|
|
Service Code
|
HCPCS J2704
|
| Hospital Charge Code |
3000563
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$16.80 |
| Max. Negotiated Rate |
$24.00 |
| Rate for Payer: Aetna Commercial |
$22.80
|
| Rate for Payer: Aetna Medicare |
$21.60
|
| Rate for Payer: BCBS MT CHIP |
$21.60
|
| Rate for Payer: BCBS MT Closed Plan Network |
$22.80
|
| Rate for Payer: BCBS MT HealthLink |
$21.60
|
| Rate for Payer: BCBS MT Medicare |
$21.60
|
| Rate for Payer: BCBS MT POS |
$22.80
|
| Rate for Payer: BCBS MT Traditional |
$24.00
|
| Rate for Payer: Cash Price |
$21.60
|
| Rate for Payer: Cigna Commercial |
$22.80
|
| Rate for Payer: Cigna Medicare |
$21.60
|
| Rate for Payer: Medicaid All Medicaid |
$22.08
|
| Rate for Payer: Medicare All Medicare |
$16.80
|
| Rate for Payer: Monida Allegiance |
$22.80
|
| Rate for Payer: Monida First Choice Health |
$23.28
|
| Rate for Payer: Monida Montana Health Co-op |
$22.80
|
| Rate for Payer: Monida PacificSource |
$22.80
|
|
|
PROPRANOLOL ER TAB [60 MG]
|
Facility
|
IP
|
$8.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
3000407
|
|
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
|
|
|
PROPRANOLOL ER TAB [60 MG]
|
Facility
|
OP
|
$8.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
3000407
|
|
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
|
|
|
PROPRANOLOL TAB [20 MG]
|
Facility
|
IP
|
$8.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
3000408
|
|
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
|
|
|
PROPRANOLOL TAB [20 MG]
|
Facility
|
OP
|
$8.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
3000408
|
|
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
|
|
