|
NEUROMUSCULAR REEDUCATION PER 15
|
Facility
|
IP
|
$109.00
|
|
|
Service Code
|
CPT 97112
|
| Hospital Charge Code |
8197112
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$76.30 |
| Max. Negotiated Rate |
$109.00 |
| Rate for Payer: Aetna Commercial |
$103.55
|
| Rate for Payer: Aetna Medicare |
$98.10
|
| Rate for Payer: BCBS MT CHIP |
$98.10
|
| Rate for Payer: BCBS MT Closed Plan Network |
$103.55
|
| Rate for Payer: BCBS MT HealthLink |
$98.10
|
| Rate for Payer: BCBS MT Medicare |
$98.10
|
| Rate for Payer: BCBS MT POS |
$103.55
|
| Rate for Payer: BCBS MT Traditional |
$109.00
|
| Rate for Payer: Cash Price |
$98.10
|
| Rate for Payer: Cigna Commercial |
$103.55
|
| Rate for Payer: Cigna Medicare |
$98.10
|
| Rate for Payer: Medicaid All Medicaid |
$100.28
|
| Rate for Payer: Medicare All Medicare |
$76.30
|
| Rate for Payer: Monida Allegiance |
$103.55
|
| Rate for Payer: Monida First Choice Health |
$105.73
|
| Rate for Payer: Monida Montana Health Co-op |
$103.55
|
| Rate for Payer: Monida PacificSource |
$103.55
|
|
|
NEUTROPHIL OXIDATIVE BURST ASSAY DHR
|
Facility
|
OP
|
$250.00
|
|
|
Service Code
|
CPT 86352
|
| Hospital Charge Code |
4088111
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$175.00 |
| Max. Negotiated Rate |
$250.00 |
| Rate for Payer: Aetna Commercial |
$237.50
|
| Rate for Payer: Aetna Medicare |
$225.00
|
| Rate for Payer: BCBS MT CHIP |
$225.00
|
| Rate for Payer: BCBS MT Closed Plan Network |
$237.50
|
| Rate for Payer: BCBS MT HealthLink |
$225.00
|
| Rate for Payer: BCBS MT Medicare |
$225.00
|
| Rate for Payer: BCBS MT POS |
$237.50
|
| Rate for Payer: BCBS MT Traditional |
$250.00
|
| Rate for Payer: Cash Price |
$225.00
|
| Rate for Payer: Cigna Commercial |
$237.50
|
| Rate for Payer: Cigna Medicare |
$225.00
|
| Rate for Payer: Medicaid All Medicaid |
$230.00
|
| Rate for Payer: Medicare All Medicare |
$175.00
|
| Rate for Payer: Monida Allegiance |
$237.50
|
| Rate for Payer: Monida First Choice Health |
$242.50
|
| Rate for Payer: Monida Montana Health Co-op |
$237.50
|
| Rate for Payer: Monida PacificSource |
$237.50
|
|
|
NEUTROPHIL OXIDATIVE BURST ASSAY DHR
|
Facility
|
IP
|
$250.00
|
|
|
Service Code
|
CPT 86352
|
| Hospital Charge Code |
4088111
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$175.00 |
| Max. Negotiated Rate |
$250.00 |
| Rate for Payer: Aetna Commercial |
$237.50
|
| Rate for Payer: Aetna Medicare |
$225.00
|
| Rate for Payer: BCBS MT CHIP |
$225.00
|
| Rate for Payer: BCBS MT Closed Plan Network |
$237.50
|
| Rate for Payer: BCBS MT HealthLink |
$225.00
|
| Rate for Payer: BCBS MT Medicare |
$225.00
|
| Rate for Payer: BCBS MT POS |
$237.50
|
| Rate for Payer: BCBS MT Traditional |
$250.00
|
| Rate for Payer: Cash Price |
$225.00
|
| Rate for Payer: Cigna Commercial |
$237.50
|
| Rate for Payer: Cigna Medicare |
$225.00
|
| Rate for Payer: Medicaid All Medicaid |
$230.00
|
| Rate for Payer: Medicare All Medicare |
$175.00
|
| Rate for Payer: Monida Allegiance |
$237.50
|
| Rate for Payer: Monida First Choice Health |
$242.50
|
| Rate for Payer: Monida Montana Health Co-op |
$237.50
|
| Rate for Payer: Monida PacificSource |
$237.50
|
|
|
NEWBORN SCREENING PANEL
|
Facility
|
OP
|
$158.00
|
|
|
Service Code
|
CPT 84030
|
| Hospital Charge Code |
4002017
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$110.60 |
| Max. Negotiated Rate |
$158.00 |
| Rate for Payer: Aetna Commercial |
$150.10
|
| Rate for Payer: Aetna Medicare |
$142.20
|
| Rate for Payer: BCBS MT CHIP |
$142.20
|
| Rate for Payer: BCBS MT Closed Plan Network |
$150.10
|
| Rate for Payer: BCBS MT HealthLink |
$142.20
|
| Rate for Payer: BCBS MT Medicare |
$142.20
|
| Rate for Payer: BCBS MT POS |
$150.10
|
| Rate for Payer: BCBS MT Traditional |
$158.00
|
| Rate for Payer: Cash Price |
$142.20
|
| Rate for Payer: Cigna Commercial |
$150.10
|
| Rate for Payer: Cigna Medicare |
$142.20
|
| Rate for Payer: Medicaid All Medicaid |
$145.36
|
| Rate for Payer: Medicare All Medicare |
$110.60
|
| Rate for Payer: Monida Allegiance |
$150.10
|
| Rate for Payer: Monida First Choice Health |
$153.26
|
| Rate for Payer: Monida Montana Health Co-op |
$150.10
|
| Rate for Payer: Monida PacificSource |
$150.10
|
|
|
NEWBORN SCREENING PANEL
|
Facility
|
IP
|
$158.00
|
|
|
Service Code
|
CPT 84030
|
| Hospital Charge Code |
4002017
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$110.60 |
| Max. Negotiated Rate |
$158.00 |
| Rate for Payer: Aetna Commercial |
$150.10
|
| Rate for Payer: Aetna Medicare |
$142.20
|
| Rate for Payer: BCBS MT CHIP |
$142.20
|
| Rate for Payer: BCBS MT Closed Plan Network |
$150.10
|
| Rate for Payer: BCBS MT HealthLink |
$142.20
|
| Rate for Payer: BCBS MT Medicare |
$142.20
|
| Rate for Payer: BCBS MT POS |
$150.10
|
| Rate for Payer: BCBS MT Traditional |
$158.00
|
| Rate for Payer: Cash Price |
$142.20
|
| Rate for Payer: Cigna Commercial |
$150.10
|
| Rate for Payer: Cigna Medicare |
$142.20
|
| Rate for Payer: Medicaid All Medicaid |
$145.36
|
| Rate for Payer: Medicare All Medicare |
$110.60
|
| Rate for Payer: Monida Allegiance |
$150.10
|
| Rate for Payer: Monida First Choice Health |
$153.26
|
| Rate for Payer: Monida Montana Health Co-op |
$150.10
|
| Rate for Payer: Monida PacificSource |
$150.10
|
|
|
NEXPLANON ETONOGESTREL IMPLANT NF
|
Facility
|
IP
|
$5.00
|
|
|
Service Code
|
HCPCS J7307
|
| Hospital Charge Code |
3000567
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$3.50 |
| Max. Negotiated Rate |
$5.00 |
| Rate for Payer: Aetna Commercial |
$4.75
|
| Rate for Payer: Aetna Medicare |
$4.50
|
| Rate for Payer: BCBS MT CHIP |
$4.50
|
| Rate for Payer: BCBS MT Closed Plan Network |
$4.75
|
| Rate for Payer: BCBS MT HealthLink |
$4.50
|
| Rate for Payer: BCBS MT Medicare |
$4.50
|
| Rate for Payer: BCBS MT POS |
$4.75
|
| Rate for Payer: BCBS MT Traditional |
$5.00
|
| Rate for Payer: Cash Price |
$4.50
|
| Rate for Payer: Cigna Commercial |
$4.75
|
| Rate for Payer: Cigna Medicare |
$4.50
|
| Rate for Payer: Medicaid All Medicaid |
$4.60
|
| Rate for Payer: Medicare All Medicare |
$3.50
|
| Rate for Payer: Monida Allegiance |
$4.75
|
| Rate for Payer: Monida First Choice Health |
$4.85
|
| Rate for Payer: Monida Montana Health Co-op |
$4.75
|
| Rate for Payer: Monida PacificSource |
$4.75
|
|
|
NEXPLANON ETONOGESTREL IMPLANT NF
|
Facility
|
OP
|
$5.00
|
|
|
Service Code
|
HCPCS J7307
|
| Hospital Charge Code |
3000567
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$3.50 |
| Max. Negotiated Rate |
$5.00 |
| Rate for Payer: Aetna Commercial |
$4.75
|
| Rate for Payer: Aetna Medicare |
$4.50
|
| Rate for Payer: BCBS MT CHIP |
$4.50
|
| Rate for Payer: BCBS MT Closed Plan Network |
$4.75
|
| Rate for Payer: BCBS MT HealthLink |
$4.50
|
| Rate for Payer: BCBS MT Medicare |
$4.50
|
| Rate for Payer: BCBS MT POS |
$4.75
|
| Rate for Payer: BCBS MT Traditional |
$5.00
|
| Rate for Payer: Cash Price |
$4.50
|
| Rate for Payer: Cigna Commercial |
$4.75
|
| Rate for Payer: Cigna Medicare |
$4.50
|
| Rate for Payer: Medicaid All Medicaid |
$4.60
|
| Rate for Payer: Medicare All Medicare |
$3.50
|
| Rate for Payer: Monida Allegiance |
$4.75
|
| Rate for Payer: Monida First Choice Health |
$4.85
|
| Rate for Payer: Monida Montana Health Co-op |
$4.75
|
| Rate for Payer: Monida PacificSource |
$4.75
|
|
|
NIACIN TAB [500 MG] NF
|
Facility
|
OP
|
$8.00
|
|
|
Service Code
|
HCPCS A9150
|
| Hospital Charge Code |
3000508
|
|
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
|
|
|
NIACIN TAB [500 MG] NF
|
Facility
|
IP
|
$8.00
|
|
|
Service Code
|
HCPCS A9150
|
| Hospital Charge Code |
3000508
|
|
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
|
|
|
NICARDIPINE [20 MG/200 ML] PREMIX
|
Facility
|
OP
|
$313.00
|
|
|
Service Code
|
HCPCS J2404
|
| Hospital Charge Code |
3007218
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$219.10 |
| Max. Negotiated Rate |
$313.00 |
| Rate for Payer: Aetna Commercial |
$297.35
|
| Rate for Payer: Aetna Medicare |
$281.70
|
| Rate for Payer: BCBS MT CHIP |
$281.70
|
| Rate for Payer: BCBS MT Closed Plan Network |
$297.35
|
| Rate for Payer: BCBS MT HealthLink |
$281.70
|
| Rate for Payer: BCBS MT Medicare |
$281.70
|
| Rate for Payer: BCBS MT POS |
$297.35
|
| Rate for Payer: BCBS MT Traditional |
$313.00
|
| Rate for Payer: Cash Price |
$281.70
|
| Rate for Payer: Cigna Commercial |
$297.35
|
| Rate for Payer: Cigna Medicare |
$281.70
|
| Rate for Payer: Medicaid All Medicaid |
$287.96
|
| Rate for Payer: Medicare All Medicare |
$219.10
|
| Rate for Payer: Monida Allegiance |
$297.35
|
| Rate for Payer: Monida First Choice Health |
$303.61
|
| Rate for Payer: Monida Montana Health Co-op |
$297.35
|
| Rate for Payer: Monida PacificSource |
$297.35
|
|
|
NICARDIPINE [20 MG/200 ML] PREMIX
|
Facility
|
IP
|
$313.00
|
|
|
Service Code
|
HCPCS J2404
|
| Hospital Charge Code |
3007218
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$219.10 |
| Max. Negotiated Rate |
$313.00 |
| Rate for Payer: Aetna Commercial |
$297.35
|
| Rate for Payer: Aetna Medicare |
$281.70
|
| Rate for Payer: BCBS MT CHIP |
$281.70
|
| Rate for Payer: BCBS MT Closed Plan Network |
$297.35
|
| Rate for Payer: BCBS MT HealthLink |
$281.70
|
| Rate for Payer: BCBS MT Medicare |
$281.70
|
| Rate for Payer: BCBS MT POS |
$297.35
|
| Rate for Payer: BCBS MT Traditional |
$313.00
|
| Rate for Payer: Cash Price |
$281.70
|
| Rate for Payer: Cigna Commercial |
$297.35
|
| Rate for Payer: Cigna Medicare |
$281.70
|
| Rate for Payer: Medicaid All Medicaid |
$287.96
|
| Rate for Payer: Medicare All Medicare |
$219.10
|
| Rate for Payer: Monida Allegiance |
$297.35
|
| Rate for Payer: Monida First Choice Health |
$303.61
|
| Rate for Payer: Monida Montana Health Co-op |
$297.35
|
| Rate for Payer: Monida PacificSource |
$297.35
|
|
|
NICOTINE GUM [4 MG] NF
|
Facility
|
IP
|
$5.00
|
|
|
Service Code
|
HCPCS A9150
|
| Hospital Charge Code |
3007714
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.50 |
| Max. Negotiated Rate |
$5.00 |
| Rate for Payer: Aetna Commercial |
$4.75
|
| Rate for Payer: Aetna Medicare |
$4.50
|
| Rate for Payer: BCBS MT CHIP |
$4.50
|
| Rate for Payer: BCBS MT Closed Plan Network |
$4.75
|
| Rate for Payer: BCBS MT HealthLink |
$4.50
|
| Rate for Payer: BCBS MT Medicare |
$4.50
|
| Rate for Payer: BCBS MT POS |
$4.75
|
| Rate for Payer: BCBS MT Traditional |
$5.00
|
| Rate for Payer: Cash Price |
$4.50
|
| Rate for Payer: Cigna Commercial |
$4.75
|
| Rate for Payer: Cigna Medicare |
$4.50
|
| Rate for Payer: Medicaid All Medicaid |
$4.60
|
| Rate for Payer: Medicare All Medicare |
$3.50
|
| Rate for Payer: Monida Allegiance |
$4.75
|
| Rate for Payer: Monida First Choice Health |
$4.85
|
| Rate for Payer: Monida Montana Health Co-op |
$4.75
|
| Rate for Payer: Monida PacificSource |
$4.75
|
|
|
NICOTINE GUM [4 MG] NF
|
Facility
|
OP
|
$5.00
|
|
|
Service Code
|
HCPCS A9150
|
| Hospital Charge Code |
3007714
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.50 |
| Max. Negotiated Rate |
$5.00 |
| Rate for Payer: Aetna Commercial |
$4.75
|
| Rate for Payer: Aetna Medicare |
$4.50
|
| Rate for Payer: BCBS MT CHIP |
$4.50
|
| Rate for Payer: BCBS MT Closed Plan Network |
$4.75
|
| Rate for Payer: BCBS MT HealthLink |
$4.50
|
| Rate for Payer: BCBS MT Medicare |
$4.50
|
| Rate for Payer: BCBS MT POS |
$4.75
|
| Rate for Payer: BCBS MT Traditional |
$5.00
|
| Rate for Payer: Cash Price |
$4.50
|
| Rate for Payer: Cigna Commercial |
$4.75
|
| Rate for Payer: Cigna Medicare |
$4.50
|
| Rate for Payer: Medicaid All Medicaid |
$4.60
|
| Rate for Payer: Medicare All Medicare |
$3.50
|
| Rate for Payer: Monida Allegiance |
$4.75
|
| Rate for Payer: Monida First Choice Health |
$4.85
|
| Rate for Payer: Monida Montana Health Co-op |
$4.75
|
| Rate for Payer: Monida PacificSource |
$4.75
|
|
|
NICOTINE PATCH [14 MG/24 HR]
|
Facility
|
IP
|
$12.00
|
|
|
Service Code
|
HCPCS A9150
|
| Hospital Charge Code |
3000518
|
|
Hospital Revenue Code
|
259
|
| 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 MT CHIP |
$10.80
|
| Rate for Payer: BCBS MT Closed Plan Network |
$11.40
|
| Rate for Payer: BCBS MT HealthLink |
$10.80
|
| Rate for Payer: BCBS MT Medicare |
$10.80
|
| Rate for Payer: BCBS MT POS |
$11.40
|
| Rate for Payer: BCBS MT Traditional |
$12.00
|
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Cigna Commercial |
$11.40
|
| Rate for Payer: Cigna Medicare |
$10.80
|
| Rate for Payer: Medicaid All Medicaid |
$11.04
|
| Rate for Payer: Medicare All Medicare |
$8.40
|
| Rate for Payer: Monida Allegiance |
$11.40
|
| Rate for Payer: Monida First Choice Health |
$11.64
|
| Rate for Payer: Monida Montana Health Co-op |
$11.40
|
| Rate for Payer: Monida PacificSource |
$11.40
|
|
|
NICOTINE PATCH [14 MG/24 HR]
|
Facility
|
OP
|
$12.00
|
|
|
Service Code
|
HCPCS A9150
|
| Hospital Charge Code |
3000518
|
|
Hospital Revenue Code
|
259
|
| 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 MT CHIP |
$10.80
|
| Rate for Payer: BCBS MT Closed Plan Network |
$11.40
|
| Rate for Payer: BCBS MT HealthLink |
$10.80
|
| Rate for Payer: BCBS MT Medicare |
$10.80
|
| Rate for Payer: BCBS MT POS |
$11.40
|
| Rate for Payer: BCBS MT Traditional |
$12.00
|
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Cigna Commercial |
$11.40
|
| Rate for Payer: Cigna Medicare |
$10.80
|
| Rate for Payer: Medicaid All Medicaid |
$11.04
|
| Rate for Payer: Medicare All Medicare |
$8.40
|
| Rate for Payer: Monida Allegiance |
$11.40
|
| Rate for Payer: Monida First Choice Health |
$11.64
|
| Rate for Payer: Monida Montana Health Co-op |
$11.40
|
| Rate for Payer: Monida PacificSource |
$11.40
|
|
|
NICOTINE PATCH [21 MG/24 HR]
|
Facility
|
OP
|
$8.00
|
|
|
Service Code
|
HCPCS A9150
|
| Hospital Charge Code |
3000346
|
|
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
|
|
|
NICOTINE PATCH [21 MG/24 HR]
|
Facility
|
IP
|
$8.00
|
|
|
Service Code
|
HCPCS A9150
|
| Hospital Charge Code |
3000346
|
|
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
|
|
|
NICOTINE PATCH [7 MG/24 HR]
|
Facility
|
IP
|
$8.00
|
|
|
Service Code
|
HCPCS A9150
|
| Hospital Charge Code |
3007154
|
|
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
|
|
|
NICOTINE PATCH [7 MG/24 HR]
|
Facility
|
OP
|
$8.00
|
|
|
Service Code
|
HCPCS A9150
|
| Hospital Charge Code |
3007154
|
|
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
|
|
|
NIFEDIPINE CAP [10 MG] NF
|
Facility
|
IP
|
$8.00
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
3007704
|
|
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
|
|
|
NIFEDIPINE CAP [10 MG] NF
|
Facility
|
OP
|
$8.00
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
3007704
|
|
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
|
|
|
NIFEDIPINE ER TAB [30 MG] NF
|
Facility
|
IP
|
$8.00
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
3000347
|
|
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
|
|
|
NIFEDIPINE ER TAB [30 MG] NF
|
Facility
|
OP
|
$8.00
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
3000347
|
|
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
|
|
|
NITAZOXANIDE TAB [500 MG] NF
|
Facility
|
OP
|
$480.00
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
3007739
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$336.00 |
| Max. Negotiated Rate |
$480.00 |
| Rate for Payer: Aetna Commercial |
$456.00
|
| Rate for Payer: Aetna Medicare |
$432.00
|
| Rate for Payer: BCBS MT CHIP |
$432.00
|
| Rate for Payer: BCBS MT Closed Plan Network |
$456.00
|
| Rate for Payer: BCBS MT HealthLink |
$432.00
|
| Rate for Payer: BCBS MT Medicare |
$432.00
|
| Rate for Payer: BCBS MT POS |
$456.00
|
| Rate for Payer: BCBS MT Traditional |
$480.00
|
| Rate for Payer: Cash Price |
$432.00
|
| Rate for Payer: Cigna Commercial |
$456.00
|
| Rate for Payer: Cigna Medicare |
$432.00
|
| Rate for Payer: Medicaid All Medicaid |
$441.60
|
| Rate for Payer: Medicare All Medicare |
$336.00
|
| Rate for Payer: Monida Allegiance |
$456.00
|
| Rate for Payer: Monida First Choice Health |
$465.60
|
| Rate for Payer: Monida Montana Health Co-op |
$456.00
|
| Rate for Payer: Monida PacificSource |
$456.00
|
|
|
NITAZOXANIDE TAB [500 MG] NF
|
Facility
|
IP
|
$480.00
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
3007739
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$336.00 |
| Max. Negotiated Rate |
$480.00 |
| Rate for Payer: Aetna Commercial |
$456.00
|
| Rate for Payer: Aetna Medicare |
$432.00
|
| Rate for Payer: BCBS MT CHIP |
$432.00
|
| Rate for Payer: BCBS MT Closed Plan Network |
$456.00
|
| Rate for Payer: BCBS MT HealthLink |
$432.00
|
| Rate for Payer: BCBS MT Medicare |
$432.00
|
| Rate for Payer: BCBS MT POS |
$456.00
|
| Rate for Payer: BCBS MT Traditional |
$480.00
|
| Rate for Payer: Cash Price |
$432.00
|
| Rate for Payer: Cigna Commercial |
$456.00
|
| Rate for Payer: Cigna Medicare |
$432.00
|
| Rate for Payer: Medicaid All Medicaid |
$441.60
|
| Rate for Payer: Medicare All Medicare |
$336.00
|
| Rate for Payer: Monida Allegiance |
$456.00
|
| Rate for Payer: Monida First Choice Health |
$465.60
|
| Rate for Payer: Monida Montana Health Co-op |
$456.00
|
| Rate for Payer: Monida PacificSource |
$456.00
|
|
