|
LIPID PANEL
|
Facility
|
OP
|
$155.00
|
|
|
Service Code
|
CPT 80061
|
| Hospital Charge Code |
4080061
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$108.50 |
| Max. Negotiated Rate |
$155.00 |
| Rate for Payer: Aetna Commercial |
$147.25
|
| Rate for Payer: Aetna Medicare |
$139.50
|
| Rate for Payer: BCBS MT CHIP |
$139.50
|
| Rate for Payer: BCBS MT Closed Plan Network |
$147.25
|
| Rate for Payer: BCBS MT HealthLink |
$139.50
|
| Rate for Payer: BCBS MT Medicare |
$139.50
|
| Rate for Payer: BCBS MT POS |
$147.25
|
| Rate for Payer: BCBS MT Traditional |
$155.00
|
| Rate for Payer: Cash Price |
$139.50
|
| Rate for Payer: Cigna Commercial |
$147.25
|
| Rate for Payer: Cigna Medicare |
$139.50
|
| Rate for Payer: Medicaid All Medicaid |
$142.60
|
| Rate for Payer: Medicare All Medicare |
$108.50
|
| Rate for Payer: Monida Allegiance |
$147.25
|
| Rate for Payer: Monida First Choice Health |
$150.35
|
| Rate for Payer: Monida Montana Health Co-op |
$147.25
|
| Rate for Payer: Monida PacificSource |
$147.25
|
|
|
LIPID PANEL
|
Facility
|
IP
|
$155.00
|
|
|
Service Code
|
CPT 80061
|
| Hospital Charge Code |
4080061
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$108.50 |
| Max. Negotiated Rate |
$155.00 |
| Rate for Payer: Aetna Commercial |
$147.25
|
| Rate for Payer: Aetna Medicare |
$139.50
|
| Rate for Payer: BCBS MT CHIP |
$139.50
|
| Rate for Payer: BCBS MT Closed Plan Network |
$147.25
|
| Rate for Payer: BCBS MT HealthLink |
$139.50
|
| Rate for Payer: BCBS MT Medicare |
$139.50
|
| Rate for Payer: BCBS MT POS |
$147.25
|
| Rate for Payer: BCBS MT Traditional |
$155.00
|
| Rate for Payer: Cash Price |
$139.50
|
| Rate for Payer: Cigna Commercial |
$147.25
|
| Rate for Payer: Cigna Medicare |
$139.50
|
| Rate for Payer: Medicaid All Medicaid |
$142.60
|
| Rate for Payer: Medicare All Medicare |
$108.50
|
| Rate for Payer: Monida Allegiance |
$147.25
|
| Rate for Payer: Monida First Choice Health |
$150.35
|
| Rate for Payer: Monida Montana Health Co-op |
$147.25
|
| Rate for Payer: Monida PacificSource |
$147.25
|
|
|
LIPID PANEL W/ DIRECT LDL REFLEX
|
Facility
|
OP
|
$155.00
|
|
|
Service Code
|
CPT 80061
|
| Hospital Charge Code |
4000611
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$108.50 |
| Max. Negotiated Rate |
$155.00 |
| Rate for Payer: Aetna Commercial |
$147.25
|
| Rate for Payer: Aetna Medicare |
$139.50
|
| Rate for Payer: BCBS MT CHIP |
$139.50
|
| Rate for Payer: BCBS MT Closed Plan Network |
$147.25
|
| Rate for Payer: BCBS MT HealthLink |
$139.50
|
| Rate for Payer: BCBS MT Medicare |
$139.50
|
| Rate for Payer: BCBS MT POS |
$147.25
|
| Rate for Payer: BCBS MT Traditional |
$155.00
|
| Rate for Payer: Cash Price |
$139.50
|
| Rate for Payer: Cigna Commercial |
$147.25
|
| Rate for Payer: Cigna Medicare |
$139.50
|
| Rate for Payer: Medicaid All Medicaid |
$142.60
|
| Rate for Payer: Medicare All Medicare |
$108.50
|
| Rate for Payer: Monida Allegiance |
$147.25
|
| Rate for Payer: Monida First Choice Health |
$150.35
|
| Rate for Payer: Monida Montana Health Co-op |
$147.25
|
| Rate for Payer: Monida PacificSource |
$147.25
|
|
|
LIPID PANEL W/ DIRECT LDL REFLEX
|
Facility
|
IP
|
$155.00
|
|
|
Service Code
|
CPT 80061
|
| Hospital Charge Code |
4000611
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$108.50 |
| Max. Negotiated Rate |
$155.00 |
| Rate for Payer: Aetna Commercial |
$147.25
|
| Rate for Payer: Aetna Medicare |
$139.50
|
| Rate for Payer: BCBS MT CHIP |
$139.50
|
| Rate for Payer: BCBS MT Closed Plan Network |
$147.25
|
| Rate for Payer: BCBS MT HealthLink |
$139.50
|
| Rate for Payer: BCBS MT Medicare |
$139.50
|
| Rate for Payer: BCBS MT POS |
$147.25
|
| Rate for Payer: BCBS MT Traditional |
$155.00
|
| Rate for Payer: Cash Price |
$139.50
|
| Rate for Payer: Cigna Commercial |
$147.25
|
| Rate for Payer: Cigna Medicare |
$139.50
|
| Rate for Payer: Medicaid All Medicaid |
$142.60
|
| Rate for Payer: Medicare All Medicare |
$108.50
|
| Rate for Payer: Monida Allegiance |
$147.25
|
| Rate for Payer: Monida First Choice Health |
$150.35
|
| Rate for Payer: Monida Montana Health Co-op |
$147.25
|
| Rate for Payer: Monida PacificSource |
$147.25
|
|
|
LIPL CALIBRATOR
|
Facility
|
OP
|
$42.28
|
|
| Hospital Charge Code |
90195034
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$29.60 |
| Max. Negotiated Rate |
$42.28 |
| Rate for Payer: Aetna Commercial |
$40.17
|
| Rate for Payer: Aetna Medicare |
$38.05
|
| Rate for Payer: BCBS MT CHIP |
$38.05
|
| Rate for Payer: BCBS MT Closed Plan Network |
$40.17
|
| Rate for Payer: BCBS MT HealthLink |
$38.05
|
| Rate for Payer: BCBS MT Medicare |
$38.05
|
| Rate for Payer: BCBS MT POS |
$40.17
|
| Rate for Payer: BCBS MT Traditional |
$42.28
|
| Rate for Payer: Cash Price |
$38.05
|
| Rate for Payer: Cigna Commercial |
$40.17
|
| Rate for Payer: Cigna Medicare |
$38.05
|
| Rate for Payer: Medicaid All Medicaid |
$38.90
|
| Rate for Payer: Medicare All Medicare |
$29.60
|
| Rate for Payer: Monida Allegiance |
$40.17
|
| Rate for Payer: Monida First Choice Health |
$41.01
|
| Rate for Payer: Monida Montana Health Co-op |
$40.17
|
| Rate for Payer: Monida PacificSource |
$40.17
|
|
|
LIPL CALIBRATOR
|
Facility
|
IP
|
$42.28
|
|
| Hospital Charge Code |
90195034
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$29.60 |
| Max. Negotiated Rate |
$42.28 |
| Rate for Payer: Aetna Commercial |
$40.17
|
| Rate for Payer: Aetna Medicare |
$38.05
|
| Rate for Payer: BCBS MT CHIP |
$38.05
|
| Rate for Payer: BCBS MT Closed Plan Network |
$40.17
|
| Rate for Payer: BCBS MT HealthLink |
$38.05
|
| Rate for Payer: BCBS MT Medicare |
$38.05
|
| Rate for Payer: BCBS MT POS |
$40.17
|
| Rate for Payer: BCBS MT Traditional |
$42.28
|
| Rate for Payer: Cash Price |
$38.05
|
| Rate for Payer: Cigna Commercial |
$40.17
|
| Rate for Payer: Cigna Medicare |
$38.05
|
| Rate for Payer: Medicaid All Medicaid |
$38.90
|
| Rate for Payer: Medicare All Medicare |
$29.60
|
| Rate for Payer: Monida Allegiance |
$40.17
|
| Rate for Payer: Monida First Choice Health |
$41.01
|
| Rate for Payer: Monida Montana Health Co-op |
$40.17
|
| Rate for Payer: Monida PacificSource |
$40.17
|
|
|
LIPOFIT BY NMR PARTICLE
|
Facility
|
OP
|
$118.00
|
|
|
Service Code
|
CPT 83704
|
| Hospital Charge Code |
4087886
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$82.60 |
| Max. Negotiated Rate |
$118.00 |
| Rate for Payer: Aetna Commercial |
$112.10
|
| Rate for Payer: Aetna Medicare |
$106.20
|
| Rate for Payer: BCBS MT CHIP |
$106.20
|
| Rate for Payer: BCBS MT Closed Plan Network |
$112.10
|
| Rate for Payer: BCBS MT HealthLink |
$106.20
|
| Rate for Payer: BCBS MT Medicare |
$106.20
|
| Rate for Payer: BCBS MT POS |
$112.10
|
| Rate for Payer: BCBS MT Traditional |
$118.00
|
| Rate for Payer: Cash Price |
$106.20
|
| Rate for Payer: Cigna Commercial |
$112.10
|
| Rate for Payer: Cigna Medicare |
$106.20
|
| Rate for Payer: Medicaid All Medicaid |
$108.56
|
| Rate for Payer: Medicare All Medicare |
$82.60
|
| Rate for Payer: Monida Allegiance |
$112.10
|
| Rate for Payer: Monida First Choice Health |
$114.46
|
| Rate for Payer: Monida Montana Health Co-op |
$112.10
|
| Rate for Payer: Monida PacificSource |
$112.10
|
|
|
LIPOFIT BY NMR PARTICLE
|
Facility
|
IP
|
$118.00
|
|
|
Service Code
|
CPT 83704
|
| Hospital Charge Code |
4087886
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$82.60 |
| Max. Negotiated Rate |
$118.00 |
| Rate for Payer: Aetna Commercial |
$112.10
|
| Rate for Payer: Aetna Medicare |
$106.20
|
| Rate for Payer: BCBS MT CHIP |
$106.20
|
| Rate for Payer: BCBS MT Closed Plan Network |
$112.10
|
| Rate for Payer: BCBS MT HealthLink |
$106.20
|
| Rate for Payer: BCBS MT Medicare |
$106.20
|
| Rate for Payer: BCBS MT POS |
$112.10
|
| Rate for Payer: BCBS MT Traditional |
$118.00
|
| Rate for Payer: Cash Price |
$106.20
|
| Rate for Payer: Cigna Commercial |
$112.10
|
| Rate for Payer: Cigna Medicare |
$106.20
|
| Rate for Payer: Medicaid All Medicaid |
$108.56
|
| Rate for Payer: Medicare All Medicare |
$82.60
|
| Rate for Payer: Monida Allegiance |
$112.10
|
| Rate for Payer: Monida First Choice Health |
$114.46
|
| Rate for Payer: Monida Montana Health Co-op |
$112.10
|
| Rate for Payer: Monida PacificSource |
$112.10
|
|
|
LIPOPROTEIN(a) (120188)
|
Facility
|
OP
|
$98.00
|
|
|
Service Code
|
CPT 83695
|
| Hospital Charge Code |
4083695
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$68.60 |
| Max. Negotiated Rate |
$98.00 |
| Rate for Payer: Aetna Commercial |
$93.10
|
| Rate for Payer: Aetna Medicare |
$88.20
|
| Rate for Payer: BCBS MT CHIP |
$88.20
|
| Rate for Payer: BCBS MT Closed Plan Network |
$93.10
|
| Rate for Payer: BCBS MT HealthLink |
$88.20
|
| Rate for Payer: BCBS MT Medicare |
$88.20
|
| Rate for Payer: BCBS MT POS |
$93.10
|
| Rate for Payer: BCBS MT Traditional |
$98.00
|
| Rate for Payer: Cash Price |
$88.20
|
| Rate for Payer: Cigna Commercial |
$93.10
|
| Rate for Payer: Cigna Medicare |
$88.20
|
| Rate for Payer: Medicaid All Medicaid |
$90.16
|
| Rate for Payer: Medicare All Medicare |
$68.60
|
| Rate for Payer: Monida Allegiance |
$93.10
|
| Rate for Payer: Monida First Choice Health |
$95.06
|
| Rate for Payer: Monida Montana Health Co-op |
$93.10
|
| Rate for Payer: Monida PacificSource |
$93.10
|
|
|
LIPOPROTEIN(a) (120188)
|
Facility
|
IP
|
$98.00
|
|
|
Service Code
|
CPT 83695
|
| Hospital Charge Code |
4083695
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$68.60 |
| Max. Negotiated Rate |
$98.00 |
| Rate for Payer: Aetna Commercial |
$93.10
|
| Rate for Payer: Aetna Medicare |
$88.20
|
| Rate for Payer: BCBS MT CHIP |
$88.20
|
| Rate for Payer: BCBS MT Closed Plan Network |
$93.10
|
| Rate for Payer: BCBS MT HealthLink |
$88.20
|
| Rate for Payer: BCBS MT Medicare |
$88.20
|
| Rate for Payer: BCBS MT POS |
$93.10
|
| Rate for Payer: BCBS MT Traditional |
$98.00
|
| Rate for Payer: Cash Price |
$88.20
|
| Rate for Payer: Cigna Commercial |
$93.10
|
| Rate for Payer: Cigna Medicare |
$88.20
|
| Rate for Payer: Medicaid All Medicaid |
$90.16
|
| Rate for Payer: Medicare All Medicare |
$68.60
|
| Rate for Payer: Monida Allegiance |
$93.10
|
| Rate for Payer: Monida First Choice Health |
$95.06
|
| Rate for Payer: Monida Montana Health Co-op |
$93.10
|
| Rate for Payer: Monida PacificSource |
$93.10
|
|
|
LIRAGLUTIDE (VICTOZA) 18MG/3ML PEN NF
|
Facility
|
IP
|
$620.00
|
|
|
Service Code
|
HCPCS J1815
|
| Hospital Charge Code |
3007123
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$434.00 |
| Max. Negotiated Rate |
$620.00 |
| Rate for Payer: Aetna Commercial |
$589.00
|
| Rate for Payer: Aetna Medicare |
$558.00
|
| Rate for Payer: BCBS MT CHIP |
$558.00
|
| Rate for Payer: BCBS MT Closed Plan Network |
$589.00
|
| Rate for Payer: BCBS MT HealthLink |
$558.00
|
| Rate for Payer: BCBS MT Medicare |
$558.00
|
| Rate for Payer: BCBS MT POS |
$589.00
|
| Rate for Payer: BCBS MT Traditional |
$620.00
|
| Rate for Payer: Cash Price |
$558.00
|
| Rate for Payer: Cigna Commercial |
$589.00
|
| Rate for Payer: Cigna Medicare |
$558.00
|
| Rate for Payer: Medicaid All Medicaid |
$570.40
|
| Rate for Payer: Medicare All Medicare |
$434.00
|
| Rate for Payer: Monida Allegiance |
$589.00
|
| Rate for Payer: Monida First Choice Health |
$601.40
|
| Rate for Payer: Monida Montana Health Co-op |
$589.00
|
| Rate for Payer: Monida PacificSource |
$589.00
|
|
|
LIRAGLUTIDE (VICTOZA) 18MG/3ML PEN NF
|
Facility
|
OP
|
$620.00
|
|
|
Service Code
|
HCPCS J1815
|
| Hospital Charge Code |
3007123
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$434.00 |
| Max. Negotiated Rate |
$620.00 |
| Rate for Payer: Aetna Commercial |
$589.00
|
| Rate for Payer: Aetna Medicare |
$558.00
|
| Rate for Payer: BCBS MT CHIP |
$558.00
|
| Rate for Payer: BCBS MT Closed Plan Network |
$589.00
|
| Rate for Payer: BCBS MT HealthLink |
$558.00
|
| Rate for Payer: BCBS MT Medicare |
$558.00
|
| Rate for Payer: BCBS MT POS |
$589.00
|
| Rate for Payer: BCBS MT Traditional |
$620.00
|
| Rate for Payer: Cash Price |
$558.00
|
| Rate for Payer: Cigna Commercial |
$589.00
|
| Rate for Payer: Cigna Medicare |
$558.00
|
| Rate for Payer: Medicaid All Medicaid |
$570.40
|
| Rate for Payer: Medicare All Medicare |
$434.00
|
| Rate for Payer: Monida Allegiance |
$589.00
|
| Rate for Payer: Monida First Choice Health |
$601.40
|
| Rate for Payer: Monida Montana Health Co-op |
$589.00
|
| Rate for Payer: Monida PacificSource |
$589.00
|
|
|
LISINOPRIL TAB [10 MG] NF
|
Facility
|
OP
|
$8.00
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
3000292
|
|
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
|
|
|
LISINOPRIL TAB [10 MG] NF
|
Facility
|
IP
|
$8.00
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
3000292
|
|
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
|
|
|
LISINOPRIL TAB [20 MG]
|
Facility
|
OP
|
$8.00
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
3000293
|
|
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
|
|
|
LISINOPRIL TAB [20 MG]
|
Facility
|
IP
|
$8.00
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
3000293
|
|
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
|
|
|
LISINOPRIL TAB [2.5 MG] NF
|
Facility
|
IP
|
$8.00
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
3007395
|
|
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
|
|
|
LISINOPRIL TAB [2.5 MG] NF
|
Facility
|
OP
|
$8.00
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
3007395
|
|
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
|
|
|
LISINOPRIL TAB [5 MG]
|
Facility
|
OP
|
$8.00
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
3000294
|
|
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
|
|
|
LISINOPRIL TAB [5 MG]
|
Facility
|
IP
|
$8.00
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
3000294
|
|
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
|
|
|
LITHIUM
|
Facility
|
IP
|
$80.00
|
|
|
Service Code
|
CPT 80178
|
| Hospital Charge Code |
4080178
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$56.00 |
| Max. Negotiated Rate |
$80.00 |
| Rate for Payer: Aetna Commercial |
$76.00
|
| Rate for Payer: Aetna Medicare |
$72.00
|
| Rate for Payer: BCBS MT CHIP |
$72.00
|
| Rate for Payer: BCBS MT Closed Plan Network |
$76.00
|
| Rate for Payer: BCBS MT HealthLink |
$72.00
|
| Rate for Payer: BCBS MT Medicare |
$72.00
|
| Rate for Payer: BCBS MT POS |
$76.00
|
| Rate for Payer: BCBS MT Traditional |
$80.00
|
| Rate for Payer: Cash Price |
$72.00
|
| Rate for Payer: Cigna Commercial |
$76.00
|
| Rate for Payer: Cigna Medicare |
$72.00
|
| Rate for Payer: Medicaid All Medicaid |
$73.60
|
| Rate for Payer: Medicare All Medicare |
$56.00
|
| Rate for Payer: Monida Allegiance |
$76.00
|
| Rate for Payer: Monida First Choice Health |
$77.60
|
| Rate for Payer: Monida Montana Health Co-op |
$76.00
|
| Rate for Payer: Monida PacificSource |
$76.00
|
|
|
LITHIUM
|
Facility
|
OP
|
$80.00
|
|
|
Service Code
|
CPT 80178
|
| Hospital Charge Code |
4080178
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$56.00 |
| Max. Negotiated Rate |
$80.00 |
| Rate for Payer: Aetna Commercial |
$76.00
|
| Rate for Payer: Aetna Medicare |
$72.00
|
| Rate for Payer: BCBS MT CHIP |
$72.00
|
| Rate for Payer: BCBS MT Closed Plan Network |
$76.00
|
| Rate for Payer: BCBS MT HealthLink |
$72.00
|
| Rate for Payer: BCBS MT Medicare |
$72.00
|
| Rate for Payer: BCBS MT POS |
$76.00
|
| Rate for Payer: BCBS MT Traditional |
$80.00
|
| Rate for Payer: Cash Price |
$72.00
|
| Rate for Payer: Cigna Commercial |
$76.00
|
| Rate for Payer: Cigna Medicare |
$72.00
|
| Rate for Payer: Medicaid All Medicaid |
$73.60
|
| Rate for Payer: Medicare All Medicare |
$56.00
|
| Rate for Payer: Monida Allegiance |
$76.00
|
| Rate for Payer: Monida First Choice Health |
$77.60
|
| Rate for Payer: Monida Montana Health Co-op |
$76.00
|
| Rate for Payer: Monida PacificSource |
$76.00
|
|
|
LITHIUM CARB CAP [300 MG] NF
|
Facility
|
OP
|
$8.00
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
3007709
|
|
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
|
|
|
LITHIUM CARB CAP [300 MG] NF
|
Facility
|
IP
|
$8.00
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
3007709
|
|
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
|
|
|
LIVER FIBROSIS BIOMARKER PANEL 81517
|
Facility
|
OP
|
$394.00
|
|
|
Service Code
|
CPT 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
|
|
