|
OXYBUTYNI 5MG ER TABLET-NF
|
Facility
OP
|
$12.00
|
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.40 |
| Max. Negotiated Rate |
$12.00 |
| Rate for Payer: AETNA Commercial |
$11.40
|
| Rate for Payer: AETNA Medicare |
$10.80
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$11.40
|
| Rate for Payer: BCBS Healthlink |
$10.80
|
| Rate for Payer: BCBS HMK CHIP |
$10.80
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$10.80
|
| Rate for Payer: BCBS POS |
$11.40
|
| Rate for Payer: BCBS Traditional |
$12.00
|
| Rate for Payer: CASH_PRICE |
$9.60
|
| Rate for Payer: CIGNA Commercial |
$11.40
|
| Rate for Payer: CIGNA Medicare |
$10.80
|
| Rate for Payer: HUMANA Commercial |
$10.80
|
| Rate for Payer: MEDICAID Medicaid |
$11.04
|
| Rate for Payer: MEDICARE Medicare |
$8.40
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$11.40
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$11.64
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$11.40
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$11.40
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$10.20
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$9.60
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$9.60
|
|
|
OXYBUTYNI 5MG ER TABLET-NF
|
Facility
IP
|
$12.00
|
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.40 |
| Max. Negotiated Rate |
$12.00 |
| Rate for Payer: AETNA Commercial |
$11.40
|
| Rate for Payer: AETNA Medicare |
$10.80
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$11.40
|
| Rate for Payer: BCBS Healthlink |
$10.80
|
| Rate for Payer: BCBS HMK CHIP |
$10.80
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$10.80
|
| Rate for Payer: BCBS POS |
$11.40
|
| Rate for Payer: BCBS Traditional |
$12.00
|
| Rate for Payer: CASH_PRICE |
$9.60
|
| Rate for Payer: CIGNA Commercial |
$11.40
|
| Rate for Payer: CIGNA Medicare |
$10.80
|
| Rate for Payer: HUMANA Commercial |
$10.80
|
| Rate for Payer: MEDICAID Medicaid |
$11.04
|
| Rate for Payer: MEDICARE Medicare |
$8.40
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$11.40
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$11.64
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$11.40
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$11.40
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$10.20
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$9.60
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$9.60
|
|
|
OXYBUTYNIN TAB [5 MG]
|
Facility
IP
|
$8.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
20221105
|
|
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 CLOSED PLAN NETWORK |
$7.60
|
| Rate for Payer: BCBS Healthlink |
$7.20
|
| Rate for Payer: BCBS HMK CHIP |
$7.20
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$7.20
|
| Rate for Payer: BCBS POS |
$7.60
|
| Rate for Payer: BCBS Traditional |
$8.00
|
| Rate for Payer: CASH_PRICE |
$6.40
|
| Rate for Payer: CIGNA Commercial |
$7.60
|
| Rate for Payer: CIGNA Medicare |
$7.20
|
| Rate for Payer: HUMANA Commercial |
$7.20
|
| Rate for Payer: MEDICAID Medicaid |
$7.36
|
| Rate for Payer: MEDICARE Medicare |
$5.60
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$7.60
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$7.76
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$7.60
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$7.60
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$6.80
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$6.40
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$6.40
|
|
|
OXYBUTYNIN TAB [5 MG]
|
Facility
OP
|
$8.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
20221105
|
|
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 CLOSED PLAN NETWORK |
$7.60
|
| Rate for Payer: BCBS Healthlink |
$7.20
|
| Rate for Payer: BCBS HMK CHIP |
$7.20
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$7.20
|
| Rate for Payer: BCBS POS |
$7.60
|
| Rate for Payer: BCBS Traditional |
$8.00
|
| Rate for Payer: CASH_PRICE |
$6.40
|
| Rate for Payer: CIGNA Commercial |
$7.60
|
| Rate for Payer: CIGNA Medicare |
$7.20
|
| Rate for Payer: HUMANA Commercial |
$7.20
|
| Rate for Payer: MEDICAID Medicaid |
$7.36
|
| Rate for Payer: MEDICARE Medicare |
$5.60
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$7.60
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$7.76
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$7.60
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$7.60
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$6.80
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$6.40
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$6.40
|
|
|
OXYCODONE 10MG ER-NF
|
Facility
OP
|
$19.30
|
|
| Hospital Charge Code |
20230321
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.51 |
| Max. Negotiated Rate |
$19.30 |
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$18.34
|
| Rate for Payer: AETNA Commercial |
$18.34
|
| Rate for Payer: AETNA Medicare |
$17.37
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$18.34
|
| Rate for Payer: BCBS Healthlink |
$17.37
|
| Rate for Payer: BCBS HMK CHIP |
$17.37
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$17.37
|
| Rate for Payer: BCBS POS |
$18.34
|
| Rate for Payer: BCBS Traditional |
$19.30
|
| Rate for Payer: CASH_PRICE |
$15.44
|
| Rate for Payer: CIGNA Commercial |
$18.34
|
| Rate for Payer: CIGNA Medicare |
$17.37
|
| Rate for Payer: HUMANA Commercial |
$17.37
|
| Rate for Payer: MEDICAID Medicaid |
$17.76
|
| Rate for Payer: MEDICARE Medicare |
$13.51
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$18.72
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$18.34
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$18.34
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$16.41
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$15.44
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$15.44
|
|
|
OXYCODONE 10MG ER-NF
|
Facility
IP
|
$19.30
|
|
| Hospital Charge Code |
20230321
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.51 |
| Max. Negotiated Rate |
$19.30 |
| Rate for Payer: AETNA Commercial |
$18.34
|
| Rate for Payer: AETNA Medicare |
$17.37
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$18.34
|
| Rate for Payer: BCBS Healthlink |
$17.37
|
| Rate for Payer: BCBS HMK CHIP |
$17.37
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$17.37
|
| Rate for Payer: BCBS POS |
$18.34
|
| Rate for Payer: BCBS Traditional |
$19.30
|
| Rate for Payer: CASH_PRICE |
$15.44
|
| Rate for Payer: CIGNA Commercial |
$18.34
|
| Rate for Payer: CIGNA Medicare |
$17.37
|
| Rate for Payer: HUMANA Commercial |
$17.37
|
| Rate for Payer: MEDICAID Medicaid |
$17.76
|
| Rate for Payer: MEDICARE Medicare |
$13.51
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$18.34
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$18.72
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$18.34
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$18.34
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$16.41
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$15.44
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$15.44
|
|
|
OXYCODONE ER TAB [15 MG]
|
Facility
OP
|
$8.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
20220524
|
|
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 CLOSED PLAN NETWORK |
$7.60
|
| Rate for Payer: BCBS Healthlink |
$7.20
|
| Rate for Payer: BCBS HMK CHIP |
$7.20
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$7.20
|
| Rate for Payer: BCBS POS |
$7.60
|
| Rate for Payer: BCBS Traditional |
$8.00
|
| Rate for Payer: CASH_PRICE |
$6.40
|
| Rate for Payer: CIGNA Commercial |
$7.60
|
| Rate for Payer: CIGNA Medicare |
$7.20
|
| Rate for Payer: HUMANA Commercial |
$7.20
|
| Rate for Payer: MEDICAID Medicaid |
$7.36
|
| Rate for Payer: MEDICARE Medicare |
$5.60
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$7.60
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$7.76
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$7.60
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$7.60
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$6.80
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$6.40
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$6.40
|
|
|
OXYCODONE ER TAB [15 MG]
|
Facility
IP
|
$8.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
20220524
|
|
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 CLOSED PLAN NETWORK |
$7.60
|
| Rate for Payer: BCBS Healthlink |
$7.20
|
| Rate for Payer: BCBS HMK CHIP |
$7.20
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$7.20
|
| Rate for Payer: BCBS POS |
$7.60
|
| Rate for Payer: BCBS Traditional |
$8.00
|
| Rate for Payer: CASH_PRICE |
$6.40
|
| Rate for Payer: CIGNA Commercial |
$7.60
|
| Rate for Payer: CIGNA Medicare |
$7.20
|
| Rate for Payer: HUMANA Commercial |
$7.20
|
| Rate for Payer: MEDICAID Medicaid |
$7.36
|
| Rate for Payer: MEDICARE Medicare |
$5.60
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$7.60
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$7.76
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$7.60
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$7.60
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$6.80
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$6.40
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$6.40
|
|
|
OXYCODONE HCL/APAP TAB [10 MG/325 MG]
|
Facility
IP
|
$8.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
20221105
|
|
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 CLOSED PLAN NETWORK |
$7.60
|
| Rate for Payer: BCBS Healthlink |
$7.20
|
| Rate for Payer: BCBS HMK CHIP |
$7.20
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$7.20
|
| Rate for Payer: BCBS POS |
$7.60
|
| Rate for Payer: BCBS Traditional |
$8.00
|
| Rate for Payer: CASH_PRICE |
$6.40
|
| Rate for Payer: CIGNA Commercial |
$7.60
|
| Rate for Payer: CIGNA Medicare |
$7.20
|
| Rate for Payer: HUMANA Commercial |
$7.20
|
| Rate for Payer: MEDICAID Medicaid |
$7.36
|
| Rate for Payer: MEDICARE Medicare |
$5.60
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$7.60
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$7.76
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$7.60
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$7.60
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$6.80
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$6.40
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$6.40
|
|
|
OXYCODONE HCL/APAP TAB [10 MG/325 MG]
|
Facility
OP
|
$8.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.60 |
| Max. Negotiated Rate |
$8.00 |
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$7.60
|
| Rate for Payer: AETNA Commercial |
$7.60
|
| Rate for Payer: AETNA Medicare |
$7.20
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$7.60
|
| Rate for Payer: BCBS Healthlink |
$7.20
|
| Rate for Payer: BCBS HMK CHIP |
$7.20
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$7.20
|
| Rate for Payer: BCBS POS |
$7.60
|
| Rate for Payer: BCBS Traditional |
$8.00
|
| Rate for Payer: CASH_PRICE |
$6.40
|
| Rate for Payer: CIGNA Commercial |
$7.60
|
| Rate for Payer: CIGNA Medicare |
$7.20
|
| Rate for Payer: HUMANA Commercial |
$7.20
|
| Rate for Payer: MEDICAID Medicaid |
$7.36
|
| Rate for Payer: MEDICARE Medicare |
$5.60
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$7.76
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$7.60
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$7.60
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$6.80
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$6.40
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$6.40
|
|
|
OXYCODONE TAB [5 MG]
|
Facility
IP
|
$8.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
20221105
|
|
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 CLOSED PLAN NETWORK |
$7.60
|
| Rate for Payer: BCBS Healthlink |
$7.20
|
| Rate for Payer: BCBS HMK CHIP |
$7.20
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$7.20
|
| Rate for Payer: BCBS POS |
$7.60
|
| Rate for Payer: BCBS Traditional |
$8.00
|
| Rate for Payer: CASH_PRICE |
$6.40
|
| Rate for Payer: CIGNA Commercial |
$7.60
|
| Rate for Payer: CIGNA Medicare |
$7.20
|
| Rate for Payer: HUMANA Commercial |
$7.20
|
| Rate for Payer: MEDICAID Medicaid |
$7.36
|
| Rate for Payer: MEDICARE Medicare |
$5.60
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$7.60
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$7.76
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$7.60
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$7.60
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$6.80
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$6.40
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$6.40
|
|
|
OXYCODONE TAB [5 MG]
|
Facility
OP
|
$8.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
20221105
|
|
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 CLOSED PLAN NETWORK |
$7.60
|
| Rate for Payer: BCBS Healthlink |
$7.20
|
| Rate for Payer: BCBS HMK CHIP |
$7.20
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$7.20
|
| Rate for Payer: BCBS POS |
$7.60
|
| Rate for Payer: BCBS Traditional |
$8.00
|
| Rate for Payer: CASH_PRICE |
$6.40
|
| Rate for Payer: CIGNA Commercial |
$7.60
|
| Rate for Payer: CIGNA Medicare |
$7.20
|
| Rate for Payer: HUMANA Commercial |
$7.20
|
| Rate for Payer: MEDICAID Medicaid |
$7.36
|
| Rate for Payer: MEDICARE Medicare |
$5.60
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$7.60
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$7.76
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$7.60
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$7.60
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$6.80
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$6.40
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$6.40
|
|
|
OXYCODONE TAB IR [10 MG]
|
Facility
OP
|
$8.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.60 |
| Max. Negotiated Rate |
$8.00 |
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$7.60
|
| Rate for Payer: AETNA Commercial |
$7.60
|
| Rate for Payer: AETNA Medicare |
$7.20
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$7.60
|
| Rate for Payer: BCBS Healthlink |
$7.20
|
| Rate for Payer: BCBS HMK CHIP |
$7.20
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$7.20
|
| Rate for Payer: BCBS POS |
$7.60
|
| Rate for Payer: BCBS Traditional |
$8.00
|
| Rate for Payer: CASH_PRICE |
$6.40
|
| Rate for Payer: CIGNA Commercial |
$7.60
|
| Rate for Payer: CIGNA Medicare |
$7.20
|
| Rate for Payer: HUMANA Commercial |
$7.20
|
| Rate for Payer: MEDICAID Medicaid |
$7.36
|
| Rate for Payer: MEDICARE Medicare |
$5.60
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$7.76
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$7.60
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$7.60
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$6.80
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$6.40
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$6.40
|
|
|
OXYCODONE TAB IR [10 MG]
|
Facility
IP
|
$8.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
20221105
|
|
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 CLOSED PLAN NETWORK |
$7.60
|
| Rate for Payer: BCBS Healthlink |
$7.20
|
| Rate for Payer: BCBS HMK CHIP |
$7.20
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$7.20
|
| Rate for Payer: BCBS POS |
$7.60
|
| Rate for Payer: BCBS Traditional |
$8.00
|
| Rate for Payer: CASH_PRICE |
$6.40
|
| Rate for Payer: CIGNA Commercial |
$7.60
|
| Rate for Payer: CIGNA Medicare |
$7.20
|
| Rate for Payer: HUMANA Commercial |
$7.20
|
| Rate for Payer: MEDICAID Medicaid |
$7.36
|
| Rate for Payer: MEDICARE Medicare |
$5.60
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$7.60
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$7.76
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$7.60
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$7.60
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$6.80
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$6.40
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$6.40
|
|
|
OXYGEN CANNULA 20' 25/CS
|
Facility
IP
|
$45.00
|
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$31.50 |
| Max. Negotiated Rate |
$45.00 |
| Rate for Payer: AETNA Commercial |
$42.75
|
| Rate for Payer: AETNA Medicare |
$40.50
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$42.75
|
| Rate for Payer: BCBS Healthlink |
$40.50
|
| Rate for Payer: BCBS HMK CHIP |
$40.50
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$40.50
|
| Rate for Payer: BCBS POS |
$42.75
|
| Rate for Payer: BCBS Traditional |
$45.00
|
| Rate for Payer: CASH_PRICE |
$36.00
|
| Rate for Payer: CIGNA Commercial |
$42.75
|
| Rate for Payer: CIGNA Medicare |
$40.50
|
| Rate for Payer: HUMANA Commercial |
$40.50
|
| Rate for Payer: MEDICAID Medicaid |
$41.40
|
| Rate for Payer: MEDICARE Medicare |
$31.50
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$42.75
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$43.65
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$42.75
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$42.75
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$38.25
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$36.00
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$36.00
|
|
|
OXYGEN CANNULA 20' 25/CS
|
Facility
OP
|
$45.00
|
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$31.50 |
| Max. Negotiated Rate |
$45.00 |
| Rate for Payer: AETNA Commercial |
$42.75
|
| Rate for Payer: AETNA Medicare |
$40.50
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$42.75
|
| Rate for Payer: BCBS Healthlink |
$40.50
|
| Rate for Payer: BCBS HMK CHIP |
$40.50
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$40.50
|
| Rate for Payer: BCBS POS |
$42.75
|
| Rate for Payer: BCBS Traditional |
$45.00
|
| Rate for Payer: CASH_PRICE |
$36.00
|
| Rate for Payer: CIGNA Commercial |
$42.75
|
| Rate for Payer: CIGNA Medicare |
$40.50
|
| Rate for Payer: HUMANA Commercial |
$40.50
|
| Rate for Payer: MEDICAID Medicaid |
$41.40
|
| Rate for Payer: MEDICARE Medicare |
$31.50
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$42.75
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$43.65
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$42.75
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$42.75
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$38.25
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$36.00
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$36.00
|
|
|
OXYGEN CANNULA PEDS.
|
Facility
OP
|
$19.00
|
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$13.30 |
| Max. Negotiated Rate |
$19.00 |
| Rate for Payer: AETNA Commercial |
$18.05
|
| Rate for Payer: AETNA Medicare |
$17.10
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$18.05
|
| Rate for Payer: BCBS Healthlink |
$17.10
|
| Rate for Payer: BCBS HMK CHIP |
$17.10
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$17.10
|
| Rate for Payer: BCBS POS |
$18.05
|
| Rate for Payer: BCBS Traditional |
$19.00
|
| Rate for Payer: CASH_PRICE |
$15.20
|
| Rate for Payer: CIGNA Commercial |
$18.05
|
| Rate for Payer: CIGNA Medicare |
$17.10
|
| Rate for Payer: HUMANA Commercial |
$17.10
|
| Rate for Payer: MEDICAID Medicaid |
$17.48
|
| Rate for Payer: MEDICARE Medicare |
$13.30
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$18.05
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$18.43
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$18.05
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$18.05
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$16.15
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$15.20
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$15.20
|
|
|
OXYGEN CANNULA PEDS.
|
Facility
IP
|
$19.00
|
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$13.30 |
| Max. Negotiated Rate |
$19.00 |
| Rate for Payer: AETNA Commercial |
$18.05
|
| Rate for Payer: AETNA Medicare |
$17.10
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$18.05
|
| Rate for Payer: BCBS Healthlink |
$17.10
|
| Rate for Payer: BCBS HMK CHIP |
$17.10
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$17.10
|
| Rate for Payer: BCBS POS |
$18.05
|
| Rate for Payer: BCBS Traditional |
$19.00
|
| Rate for Payer: CASH_PRICE |
$15.20
|
| Rate for Payer: CIGNA Commercial |
$18.05
|
| Rate for Payer: CIGNA Medicare |
$17.10
|
| Rate for Payer: HUMANA Commercial |
$17.10
|
| Rate for Payer: MEDICAID Medicaid |
$17.48
|
| Rate for Payer: MEDICARE Medicare |
$13.30
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$18.05
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$18.43
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$18.05
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$18.05
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$16.15
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$15.20
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$15.20
|
|
|
OXYGEN MASK NON-REBREATHER
|
Facility
OP
|
$21.00
|
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
270
|
| 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 CLOSED PLAN NETWORK |
$19.95
|
| Rate for Payer: BCBS Healthlink |
$18.90
|
| Rate for Payer: BCBS HMK CHIP |
$18.90
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$18.90
|
| Rate for Payer: BCBS POS |
$19.95
|
| Rate for Payer: BCBS Traditional |
$21.00
|
| Rate for Payer: CASH_PRICE |
$16.80
|
| Rate for Payer: CIGNA Commercial |
$19.95
|
| Rate for Payer: CIGNA Medicare |
$18.90
|
| Rate for Payer: HUMANA Commercial |
$18.90
|
| Rate for Payer: MEDICAID Medicaid |
$19.32
|
| Rate for Payer: MEDICARE Medicare |
$14.70
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$19.95
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$20.37
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$19.95
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$19.95
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$17.85
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$16.80
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$16.80
|
|
|
OXYGEN MASK NON-REBREATHER
|
Facility
IP
|
$21.00
|
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
270
|
| 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 CLOSED PLAN NETWORK |
$19.95
|
| Rate for Payer: BCBS Healthlink |
$18.90
|
| Rate for Payer: BCBS HMK CHIP |
$18.90
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$18.90
|
| Rate for Payer: BCBS POS |
$19.95
|
| Rate for Payer: BCBS Traditional |
$21.00
|
| Rate for Payer: CASH_PRICE |
$16.80
|
| Rate for Payer: CIGNA Commercial |
$19.95
|
| Rate for Payer: CIGNA Medicare |
$18.90
|
| Rate for Payer: HUMANA Commercial |
$18.90
|
| Rate for Payer: MEDICAID Medicaid |
$19.32
|
| Rate for Payer: MEDICARE Medicare |
$14.70
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$19.95
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$20.37
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$19.95
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$19.95
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$17.85
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$16.80
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$16.80
|
|
|
OXYGEN PER DAY
|
Facility
IP
|
$126.00
|
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$88.20 |
| Max. Negotiated Rate |
$126.00 |
| Rate for Payer: AETNA Commercial |
$119.70
|
| Rate for Payer: AETNA Medicare |
$113.40
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$119.70
|
| Rate for Payer: BCBS Healthlink |
$113.40
|
| Rate for Payer: BCBS HMK CHIP |
$113.40
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$113.40
|
| Rate for Payer: BCBS POS |
$119.70
|
| Rate for Payer: BCBS Traditional |
$126.00
|
| Rate for Payer: CASH_PRICE |
$100.80
|
| Rate for Payer: CIGNA Commercial |
$119.70
|
| Rate for Payer: CIGNA Medicare |
$113.40
|
| Rate for Payer: HUMANA Commercial |
$113.40
|
| Rate for Payer: MEDICAID Medicaid |
$115.92
|
| Rate for Payer: MEDICARE Medicare |
$88.20
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$119.70
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$122.22
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$119.70
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$119.70
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$107.10
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$100.80
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$100.80
|
|
|
OXYGEN PER DAY
|
Facility
OP
|
$126.00
|
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$88.20 |
| Max. Negotiated Rate |
$126.00 |
| Rate for Payer: AETNA Commercial |
$119.70
|
| Rate for Payer: AETNA Medicare |
$113.40
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$119.70
|
| Rate for Payer: BCBS Healthlink |
$113.40
|
| Rate for Payer: BCBS HMK CHIP |
$113.40
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$113.40
|
| Rate for Payer: BCBS POS |
$119.70
|
| Rate for Payer: BCBS Traditional |
$126.00
|
| Rate for Payer: CASH_PRICE |
$100.80
|
| Rate for Payer: CIGNA Commercial |
$119.70
|
| Rate for Payer: CIGNA Medicare |
$113.40
|
| Rate for Payer: HUMANA Commercial |
$113.40
|
| Rate for Payer: MEDICAID Medicaid |
$115.92
|
| Rate for Payer: MEDICARE Medicare |
$88.20
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$119.70
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$122.22
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$119.70
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$119.70
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$107.10
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$100.80
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$100.80
|
|
|
OXYMETAZOLINE NASAL [0.05%] 12HR
|
Facility
IP
|
$26.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
20221105
|
|
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 CLOSED PLAN NETWORK |
$24.70
|
| Rate for Payer: BCBS Healthlink |
$23.40
|
| Rate for Payer: BCBS HMK CHIP |
$23.40
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$23.40
|
| Rate for Payer: BCBS POS |
$24.70
|
| Rate for Payer: BCBS Traditional |
$26.00
|
| Rate for Payer: CASH_PRICE |
$20.80
|
| Rate for Payer: CIGNA Commercial |
$24.70
|
| Rate for Payer: CIGNA Medicare |
$23.40
|
| Rate for Payer: HUMANA Commercial |
$23.40
|
| Rate for Payer: MEDICAID Medicaid |
$23.92
|
| Rate for Payer: MEDICARE Medicare |
$18.20
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$24.70
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$25.22
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$24.70
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$24.70
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$22.10
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$20.80
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$20.80
|
|
|
OXYMETAZOLINE NASAL [0.05%] 12HR
|
Facility
OP
|
$26.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
20221105
|
|
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 CLOSED PLAN NETWORK |
$24.70
|
| Rate for Payer: BCBS Healthlink |
$23.40
|
| Rate for Payer: BCBS HMK CHIP |
$23.40
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$23.40
|
| Rate for Payer: BCBS POS |
$24.70
|
| Rate for Payer: BCBS Traditional |
$26.00
|
| Rate for Payer: CASH_PRICE |
$20.80
|
| Rate for Payer: CIGNA Commercial |
$24.70
|
| Rate for Payer: CIGNA Medicare |
$23.40
|
| Rate for Payer: HUMANA Commercial |
$23.40
|
| Rate for Payer: MEDICAID Medicaid |
$23.92
|
| Rate for Payer: MEDICARE Medicare |
$18.20
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$24.70
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$25.22
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$24.70
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$24.70
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$22.10
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$20.80
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$20.80
|
|
|
OXYTOCIN INJ [10 U/ML]
|
Facility
IP
|
$26.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
259
|
| 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 CLOSED PLAN NETWORK |
$24.70
|
| Rate for Payer: BCBS Healthlink |
$23.40
|
| Rate for Payer: BCBS HMK CHIP |
$23.40
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$23.40
|
| Rate for Payer: BCBS POS |
$24.70
|
| Rate for Payer: BCBS Traditional |
$26.00
|
| Rate for Payer: CASH_PRICE |
$20.80
|
| Rate for Payer: CIGNA Commercial |
$24.70
|
| Rate for Payer: CIGNA Medicare |
$23.40
|
| Rate for Payer: HUMANA Commercial |
$23.40
|
| Rate for Payer: MEDICAID Medicaid |
$23.92
|
| Rate for Payer: MEDICARE Medicare |
$18.20
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$24.70
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$25.22
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$24.70
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$24.70
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$22.10
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$20.80
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$20.80
|
|
