|
VALPROIC ACID PO SLN [250 MG/5 ML] UD
|
Facility
|
IP
|
$8.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
3000470
|
|
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
|
|
|
VALPROIC ACID PO SLN [250 MG/5 ML] UD
|
Facility
|
OP
|
$8.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
3000470
|
|
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
|
|
|
VANCOMYCIN 1.25 GM VIAL
|
Facility
|
IP
|
$77.20
|
|
|
Service Code
|
NDC 67457082399
|
| Hospital Charge Code |
3007278
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$54.04 |
| Max. Negotiated Rate |
$77.20 |
| Rate for Payer: Aetna Commercial |
$73.34
|
| Rate for Payer: Aetna Medicare |
$69.48
|
| Rate for Payer: BCBS MT CHIP |
$69.48
|
| Rate for Payer: BCBS MT Closed Plan Network |
$73.34
|
| Rate for Payer: BCBS MT HealthLink |
$69.48
|
| Rate for Payer: BCBS MT Medicare |
$69.48
|
| Rate for Payer: BCBS MT POS |
$73.34
|
| Rate for Payer: BCBS MT Traditional |
$77.20
|
| Rate for Payer: Cash Price |
$69.48
|
| Rate for Payer: Cigna Commercial |
$73.34
|
| Rate for Payer: Cigna Medicare |
$69.48
|
| Rate for Payer: Medicaid All Medicaid |
$71.02
|
| Rate for Payer: Medicare All Medicare |
$54.04
|
| Rate for Payer: Monida Allegiance |
$73.34
|
| Rate for Payer: Monida First Choice Health |
$74.88
|
| Rate for Payer: Monida Montana Health Co-op |
$73.34
|
| Rate for Payer: Monida PacificSource |
$73.34
|
|
|
VANCOMYCIN 1.25 GM VIAL
|
Facility
|
OP
|
$77.20
|
|
|
Service Code
|
NDC 67457082399
|
| Hospital Charge Code |
3007278
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$54.04 |
| Max. Negotiated Rate |
$77.20 |
| Rate for Payer: Aetna Commercial |
$73.34
|
| Rate for Payer: Aetna Medicare |
$69.48
|
| Rate for Payer: BCBS MT CHIP |
$69.48
|
| Rate for Payer: BCBS MT Closed Plan Network |
$73.34
|
| Rate for Payer: BCBS MT HealthLink |
$69.48
|
| Rate for Payer: BCBS MT Medicare |
$69.48
|
| Rate for Payer: BCBS MT POS |
$73.34
|
| Rate for Payer: BCBS MT Traditional |
$77.20
|
| Rate for Payer: Cash Price |
$69.48
|
| Rate for Payer: Cigna Commercial |
$73.34
|
| Rate for Payer: Cigna Medicare |
$69.48
|
| Rate for Payer: Medicaid All Medicaid |
$71.02
|
| Rate for Payer: Medicare All Medicare |
$54.04
|
| Rate for Payer: Monida Allegiance |
$73.34
|
| Rate for Payer: Monida First Choice Health |
$74.88
|
| Rate for Payer: Monida Montana Health Co-op |
$73.34
|
| Rate for Payer: Monida PacificSource |
$73.34
|
|
|
VANCOMYCIN 1GM VIAL
|
Facility
|
OP
|
$65.00
|
|
|
Service Code
|
HCPCS J3370
|
| Hospital Charge Code |
3000471
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$45.50 |
| Max. Negotiated Rate |
$65.00 |
| Rate for Payer: Aetna Commercial |
$61.75
|
| Rate for Payer: Aetna Medicare |
$58.50
|
| Rate for Payer: BCBS MT CHIP |
$58.50
|
| Rate for Payer: BCBS MT Closed Plan Network |
$61.75
|
| Rate for Payer: BCBS MT HealthLink |
$58.50
|
| Rate for Payer: BCBS MT Medicare |
$58.50
|
| Rate for Payer: BCBS MT POS |
$61.75
|
| Rate for Payer: BCBS MT Traditional |
$65.00
|
| Rate for Payer: Cash Price |
$58.50
|
| Rate for Payer: Cigna Commercial |
$61.75
|
| Rate for Payer: Cigna Medicare |
$58.50
|
| Rate for Payer: Medicaid All Medicaid |
$59.80
|
| Rate for Payer: Medicare All Medicare |
$45.50
|
| Rate for Payer: Monida Allegiance |
$61.75
|
| Rate for Payer: Monida First Choice Health |
$63.05
|
| Rate for Payer: Monida Montana Health Co-op |
$61.75
|
| Rate for Payer: Monida PacificSource |
$61.75
|
|
|
VANCOMYCIN 1GM VIAL
|
Facility
|
IP
|
$65.00
|
|
|
Service Code
|
HCPCS J3370
|
| Hospital Charge Code |
3000471
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$45.50 |
| Max. Negotiated Rate |
$65.00 |
| Rate for Payer: Aetna Commercial |
$61.75
|
| Rate for Payer: Aetna Medicare |
$58.50
|
| Rate for Payer: BCBS MT CHIP |
$58.50
|
| Rate for Payer: BCBS MT Closed Plan Network |
$61.75
|
| Rate for Payer: BCBS MT HealthLink |
$58.50
|
| Rate for Payer: BCBS MT Medicare |
$58.50
|
| Rate for Payer: BCBS MT POS |
$61.75
|
| Rate for Payer: BCBS MT Traditional |
$65.00
|
| Rate for Payer: Cash Price |
$58.50
|
| Rate for Payer: Cigna Commercial |
$61.75
|
| Rate for Payer: Cigna Medicare |
$58.50
|
| Rate for Payer: Medicaid All Medicaid |
$59.80
|
| Rate for Payer: Medicare All Medicare |
$45.50
|
| Rate for Payer: Monida Allegiance |
$61.75
|
| Rate for Payer: Monida First Choice Health |
$63.05
|
| Rate for Payer: Monida Montana Health Co-op |
$61.75
|
| Rate for Payer: Monida PacificSource |
$61.75
|
|
|
VANCOMYCIN 500MG VIAL
|
Facility
|
OP
|
$29.00
|
|
|
Service Code
|
HCPCS J3370
|
| Hospital Charge Code |
3000472
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$20.30 |
| Max. Negotiated Rate |
$29.00 |
| Rate for Payer: Aetna Commercial |
$27.55
|
| Rate for Payer: Aetna Medicare |
$26.10
|
| Rate for Payer: BCBS MT CHIP |
$26.10
|
| Rate for Payer: BCBS MT Closed Plan Network |
$27.55
|
| Rate for Payer: BCBS MT HealthLink |
$26.10
|
| Rate for Payer: BCBS MT Medicare |
$26.10
|
| Rate for Payer: BCBS MT POS |
$27.55
|
| Rate for Payer: BCBS MT Traditional |
$29.00
|
| Rate for Payer: Cash Price |
$26.10
|
| Rate for Payer: Cigna Commercial |
$27.55
|
| Rate for Payer: Cigna Medicare |
$26.10
|
| Rate for Payer: Medicaid All Medicaid |
$26.68
|
| Rate for Payer: Medicare All Medicare |
$20.30
|
| Rate for Payer: Monida Allegiance |
$27.55
|
| Rate for Payer: Monida First Choice Health |
$28.13
|
| Rate for Payer: Monida Montana Health Co-op |
$27.55
|
| Rate for Payer: Monida PacificSource |
$27.55
|
|
|
VANCOMYCIN 500MG VIAL
|
Facility
|
IP
|
$29.00
|
|
|
Service Code
|
HCPCS J3370
|
| Hospital Charge Code |
3000472
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$20.30 |
| Max. Negotiated Rate |
$29.00 |
| Rate for Payer: Aetna Commercial |
$27.55
|
| Rate for Payer: Aetna Medicare |
$26.10
|
| Rate for Payer: BCBS MT CHIP |
$26.10
|
| Rate for Payer: BCBS MT Closed Plan Network |
$27.55
|
| Rate for Payer: BCBS MT HealthLink |
$26.10
|
| Rate for Payer: BCBS MT Medicare |
$26.10
|
| Rate for Payer: BCBS MT POS |
$27.55
|
| Rate for Payer: BCBS MT Traditional |
$29.00
|
| Rate for Payer: Cash Price |
$26.10
|
| Rate for Payer: Cigna Commercial |
$27.55
|
| Rate for Payer: Cigna Medicare |
$26.10
|
| Rate for Payer: Medicaid All Medicaid |
$26.68
|
| Rate for Payer: Medicare All Medicare |
$20.30
|
| Rate for Payer: Monida Allegiance |
$27.55
|
| Rate for Payer: Monida First Choice Health |
$28.13
|
| Rate for Payer: Monida Montana Health Co-op |
$27.55
|
| Rate for Payer: Monida PacificSource |
$27.55
|
|
|
VANCOMYCIN CAP [125 MG]
|
Facility
|
IP
|
$101.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
3007051
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$70.70 |
| Max. Negotiated Rate |
$101.00 |
| Rate for Payer: Aetna Commercial |
$95.95
|
| Rate for Payer: Aetna Medicare |
$90.90
|
| Rate for Payer: BCBS MT CHIP |
$90.90
|
| Rate for Payer: BCBS MT Closed Plan Network |
$95.95
|
| Rate for Payer: BCBS MT HealthLink |
$90.90
|
| Rate for Payer: BCBS MT Medicare |
$90.90
|
| Rate for Payer: BCBS MT POS |
$95.95
|
| Rate for Payer: BCBS MT Traditional |
$101.00
|
| Rate for Payer: Cash Price |
$90.90
|
| Rate for Payer: Cigna Commercial |
$95.95
|
| Rate for Payer: Cigna Medicare |
$90.90
|
| Rate for Payer: Medicaid All Medicaid |
$92.92
|
| Rate for Payer: Medicare All Medicare |
$70.70
|
| Rate for Payer: Monida Allegiance |
$95.95
|
| Rate for Payer: Monida First Choice Health |
$97.97
|
| Rate for Payer: Monida Montana Health Co-op |
$95.95
|
| Rate for Payer: Monida PacificSource |
$95.95
|
|
|
VANCOMYCIN CAP [125 MG]
|
Facility
|
OP
|
$101.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
3007051
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$70.70 |
| Max. Negotiated Rate |
$101.00 |
| Rate for Payer: Aetna Commercial |
$95.95
|
| Rate for Payer: Aetna Medicare |
$90.90
|
| Rate for Payer: BCBS MT CHIP |
$90.90
|
| Rate for Payer: BCBS MT Closed Plan Network |
$95.95
|
| Rate for Payer: BCBS MT HealthLink |
$90.90
|
| Rate for Payer: BCBS MT Medicare |
$90.90
|
| Rate for Payer: BCBS MT POS |
$95.95
|
| Rate for Payer: BCBS MT Traditional |
$101.00
|
| Rate for Payer: Cash Price |
$90.90
|
| Rate for Payer: Cigna Commercial |
$95.95
|
| Rate for Payer: Cigna Medicare |
$90.90
|
| Rate for Payer: Medicaid All Medicaid |
$92.92
|
| Rate for Payer: Medicare All Medicare |
$70.70
|
| Rate for Payer: Monida Allegiance |
$95.95
|
| Rate for Payer: Monida First Choice Health |
$97.97
|
| Rate for Payer: Monida Montana Health Co-op |
$95.95
|
| Rate for Payer: Monida PacificSource |
$95.95
|
|
|
VANCOMYCIN INJ [750 MG]
|
Facility
|
IP
|
$35.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
3000565
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$24.50 |
| Max. Negotiated Rate |
$35.00 |
| Rate for Payer: Aetna Commercial |
$33.25
|
| Rate for Payer: Aetna Medicare |
$31.50
|
| Rate for Payer: BCBS MT CHIP |
$31.50
|
| Rate for Payer: BCBS MT Closed Plan Network |
$33.25
|
| Rate for Payer: BCBS MT HealthLink |
$31.50
|
| Rate for Payer: BCBS MT Medicare |
$31.50
|
| Rate for Payer: BCBS MT POS |
$33.25
|
| Rate for Payer: BCBS MT Traditional |
$35.00
|
| Rate for Payer: Cash Price |
$31.50
|
| Rate for Payer: Cigna Commercial |
$33.25
|
| Rate for Payer: Cigna Medicare |
$31.50
|
| Rate for Payer: Medicaid All Medicaid |
$32.20
|
| Rate for Payer: Medicare All Medicare |
$24.50
|
| Rate for Payer: Monida Allegiance |
$33.25
|
| Rate for Payer: Monida First Choice Health |
$33.95
|
| Rate for Payer: Monida Montana Health Co-op |
$33.25
|
| Rate for Payer: Monida PacificSource |
$33.25
|
|
|
VANCOMYCIN INJ [750 MG]
|
Facility
|
OP
|
$35.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
3000565
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$24.50 |
| Max. Negotiated Rate |
$35.00 |
| Rate for Payer: Aetna Commercial |
$33.25
|
| Rate for Payer: Aetna Medicare |
$31.50
|
| Rate for Payer: BCBS MT CHIP |
$31.50
|
| Rate for Payer: BCBS MT Closed Plan Network |
$33.25
|
| Rate for Payer: BCBS MT HealthLink |
$31.50
|
| Rate for Payer: BCBS MT Medicare |
$31.50
|
| Rate for Payer: BCBS MT POS |
$33.25
|
| Rate for Payer: BCBS MT Traditional |
$35.00
|
| Rate for Payer: Cash Price |
$31.50
|
| Rate for Payer: Cigna Commercial |
$33.25
|
| Rate for Payer: Cigna Medicare |
$31.50
|
| Rate for Payer: Medicaid All Medicaid |
$32.20
|
| Rate for Payer: Medicare All Medicare |
$24.50
|
| Rate for Payer: Monida Allegiance |
$33.25
|
| Rate for Payer: Monida First Choice Health |
$33.95
|
| Rate for Payer: Monida Montana Health Co-op |
$33.25
|
| Rate for Payer: Monida PacificSource |
$33.25
|
|
|
VANCOMYCIN, PEAK
|
Facility
|
IP
|
$182.00
|
|
|
Service Code
|
HCPCS 80202
|
| Hospital Charge Code |
4000045
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$127.40 |
| Max. Negotiated Rate |
$182.00 |
| Rate for Payer: Aetna Commercial |
$172.90
|
| Rate for Payer: Aetna Medicare |
$163.80
|
| Rate for Payer: BCBS MT CHIP |
$163.80
|
| Rate for Payer: BCBS MT Closed Plan Network |
$172.90
|
| Rate for Payer: BCBS MT HealthLink |
$163.80
|
| Rate for Payer: BCBS MT Medicare |
$163.80
|
| Rate for Payer: BCBS MT POS |
$172.90
|
| Rate for Payer: BCBS MT Traditional |
$182.00
|
| Rate for Payer: Cash Price |
$163.80
|
| Rate for Payer: Cigna Commercial |
$172.90
|
| Rate for Payer: Cigna Medicare |
$163.80
|
| Rate for Payer: Medicaid All Medicaid |
$167.44
|
| Rate for Payer: Medicare All Medicare |
$127.40
|
| Rate for Payer: Monida Allegiance |
$172.90
|
| Rate for Payer: Monida First Choice Health |
$176.54
|
| Rate for Payer: Monida Montana Health Co-op |
$172.90
|
| Rate for Payer: Monida PacificSource |
$172.90
|
|
|
VANCOMYCIN, PEAK
|
Facility
|
OP
|
$182.00
|
|
|
Service Code
|
HCPCS 80202
|
| Hospital Charge Code |
4000045
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$127.40 |
| Max. Negotiated Rate |
$182.00 |
| Rate for Payer: Aetna Commercial |
$172.90
|
| Rate for Payer: Aetna Medicare |
$163.80
|
| Rate for Payer: BCBS MT CHIP |
$163.80
|
| Rate for Payer: BCBS MT Closed Plan Network |
$172.90
|
| Rate for Payer: BCBS MT HealthLink |
$163.80
|
| Rate for Payer: BCBS MT Medicare |
$163.80
|
| Rate for Payer: BCBS MT POS |
$172.90
|
| Rate for Payer: BCBS MT Traditional |
$182.00
|
| Rate for Payer: Cash Price |
$163.80
|
| Rate for Payer: Cigna Commercial |
$172.90
|
| Rate for Payer: Cigna Medicare |
$163.80
|
| Rate for Payer: Medicaid All Medicaid |
$167.44
|
| Rate for Payer: Medicare All Medicare |
$127.40
|
| Rate for Payer: Monida Allegiance |
$172.90
|
| Rate for Payer: Monida First Choice Health |
$176.54
|
| Rate for Payer: Monida Montana Health Co-op |
$172.90
|
| Rate for Payer: Monida PacificSource |
$172.90
|
|
|
VANCOMYCIN, RANDOM
|
Facility
|
IP
|
$146.00
|
|
|
Service Code
|
HCPCS 80202
|
| Hospital Charge Code |
4080202
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$102.20 |
| Max. Negotiated Rate |
$146.00 |
| Rate for Payer: Aetna Commercial |
$138.70
|
| Rate for Payer: Aetna Medicare |
$131.40
|
| Rate for Payer: BCBS MT CHIP |
$131.40
|
| Rate for Payer: BCBS MT Closed Plan Network |
$138.70
|
| Rate for Payer: BCBS MT HealthLink |
$131.40
|
| Rate for Payer: BCBS MT Medicare |
$131.40
|
| Rate for Payer: BCBS MT POS |
$138.70
|
| Rate for Payer: BCBS MT Traditional |
$146.00
|
| Rate for Payer: Cash Price |
$131.40
|
| Rate for Payer: Cigna Commercial |
$138.70
|
| Rate for Payer: Cigna Medicare |
$131.40
|
| Rate for Payer: Medicaid All Medicaid |
$134.32
|
| Rate for Payer: Medicare All Medicare |
$102.20
|
| Rate for Payer: Monida Allegiance |
$138.70
|
| Rate for Payer: Monida First Choice Health |
$141.62
|
| Rate for Payer: Monida Montana Health Co-op |
$138.70
|
| Rate for Payer: Monida PacificSource |
$138.70
|
|
|
VANCOMYCIN, RANDOM
|
Facility
|
OP
|
$146.00
|
|
|
Service Code
|
HCPCS 80202
|
| Hospital Charge Code |
4080202
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$102.20 |
| Max. Negotiated Rate |
$146.00 |
| Rate for Payer: Aetna Commercial |
$138.70
|
| Rate for Payer: Aetna Medicare |
$131.40
|
| Rate for Payer: BCBS MT CHIP |
$131.40
|
| Rate for Payer: BCBS MT Closed Plan Network |
$138.70
|
| Rate for Payer: BCBS MT HealthLink |
$131.40
|
| Rate for Payer: BCBS MT Medicare |
$131.40
|
| Rate for Payer: BCBS MT POS |
$138.70
|
| Rate for Payer: BCBS MT Traditional |
$146.00
|
| Rate for Payer: Cash Price |
$131.40
|
| Rate for Payer: Cigna Commercial |
$138.70
|
| Rate for Payer: Cigna Medicare |
$131.40
|
| Rate for Payer: Medicaid All Medicaid |
$134.32
|
| Rate for Payer: Medicare All Medicare |
$102.20
|
| Rate for Payer: Monida Allegiance |
$138.70
|
| Rate for Payer: Monida First Choice Health |
$141.62
|
| Rate for Payer: Monida Montana Health Co-op |
$138.70
|
| Rate for Payer: Monida PacificSource |
$138.70
|
|
|
VANCOMYCIN, TROUGH
|
Facility
|
IP
|
$182.00
|
|
|
Service Code
|
HCPCS 80202
|
| Hospital Charge Code |
4000046
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$127.40 |
| Max. Negotiated Rate |
$182.00 |
| Rate for Payer: Aetna Commercial |
$172.90
|
| Rate for Payer: Aetna Medicare |
$163.80
|
| Rate for Payer: BCBS MT CHIP |
$163.80
|
| Rate for Payer: BCBS MT Closed Plan Network |
$172.90
|
| Rate for Payer: BCBS MT HealthLink |
$163.80
|
| Rate for Payer: BCBS MT Medicare |
$163.80
|
| Rate for Payer: BCBS MT POS |
$172.90
|
| Rate for Payer: BCBS MT Traditional |
$182.00
|
| Rate for Payer: Cash Price |
$163.80
|
| Rate for Payer: Cigna Commercial |
$172.90
|
| Rate for Payer: Cigna Medicare |
$163.80
|
| Rate for Payer: Medicaid All Medicaid |
$167.44
|
| Rate for Payer: Medicare All Medicare |
$127.40
|
| Rate for Payer: Monida Allegiance |
$172.90
|
| Rate for Payer: Monida First Choice Health |
$176.54
|
| Rate for Payer: Monida Montana Health Co-op |
$172.90
|
| Rate for Payer: Monida PacificSource |
$172.90
|
|
|
VANCOMYCIN, TROUGH
|
Facility
|
OP
|
$182.00
|
|
|
Service Code
|
HCPCS 80202
|
| Hospital Charge Code |
4000046
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$127.40 |
| Max. Negotiated Rate |
$182.00 |
| Rate for Payer: Aetna Commercial |
$172.90
|
| Rate for Payer: Aetna Medicare |
$163.80
|
| Rate for Payer: BCBS MT CHIP |
$163.80
|
| Rate for Payer: BCBS MT Closed Plan Network |
$172.90
|
| Rate for Payer: BCBS MT HealthLink |
$163.80
|
| Rate for Payer: BCBS MT Medicare |
$163.80
|
| Rate for Payer: BCBS MT POS |
$172.90
|
| Rate for Payer: BCBS MT Traditional |
$182.00
|
| Rate for Payer: Cash Price |
$163.80
|
| Rate for Payer: Cigna Commercial |
$172.90
|
| Rate for Payer: Cigna Medicare |
$163.80
|
| Rate for Payer: Medicaid All Medicaid |
$167.44
|
| Rate for Payer: Medicare All Medicare |
$127.40
|
| Rate for Payer: Monida Allegiance |
$172.90
|
| Rate for Payer: Monida First Choice Health |
$176.54
|
| Rate for Payer: Monida Montana Health Co-op |
$172.90
|
| Rate for Payer: Monida PacificSource |
$172.90
|
|
|
VARICELLA-ZOSTER AB, IGG (096206)
|
Facility
|
IP
|
$32.00
|
|
|
Service Code
|
HCPCS 86787
|
| Hospital Charge Code |
4086787
|
|
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
|
|
|
VARICELLA-ZOSTER AB, IGG (096206)
|
Facility
|
OP
|
$32.00
|
|
|
Service Code
|
HCPCS 86787
|
| Hospital Charge Code |
4086787
|
|
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
|
|
|
.VENIPUNCTURE
|
Facility
|
IP
|
$29.00
|
|
|
Service Code
|
HCPCS 36415
|
| Hospital Charge Code |
4036415
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$20.30 |
| Max. Negotiated Rate |
$29.00 |
| Rate for Payer: Aetna Commercial |
$27.55
|
| Rate for Payer: Aetna Medicare |
$26.10
|
| Rate for Payer: BCBS MT CHIP |
$26.10
|
| Rate for Payer: BCBS MT Closed Plan Network |
$27.55
|
| Rate for Payer: BCBS MT HealthLink |
$26.10
|
| Rate for Payer: BCBS MT Medicare |
$26.10
|
| Rate for Payer: BCBS MT POS |
$27.55
|
| Rate for Payer: BCBS MT Traditional |
$29.00
|
| Rate for Payer: Cash Price |
$26.10
|
| Rate for Payer: Cigna Commercial |
$27.55
|
| Rate for Payer: Cigna Medicare |
$26.10
|
| Rate for Payer: Medicaid All Medicaid |
$26.68
|
| Rate for Payer: Medicare All Medicare |
$20.30
|
| Rate for Payer: Monida Allegiance |
$27.55
|
| Rate for Payer: Monida First Choice Health |
$28.13
|
| Rate for Payer: Monida Montana Health Co-op |
$27.55
|
| Rate for Payer: Monida PacificSource |
$27.55
|
|
|
.VENIPUNCTURE
|
Facility
|
OP
|
$29.00
|
|
|
Service Code
|
HCPCS 36415
|
| Hospital Charge Code |
4036415
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$20.30 |
| Max. Negotiated Rate |
$29.00 |
| Rate for Payer: Aetna Commercial |
$27.55
|
| Rate for Payer: Aetna Medicare |
$26.10
|
| Rate for Payer: BCBS MT CHIP |
$26.10
|
| Rate for Payer: BCBS MT Closed Plan Network |
$27.55
|
| Rate for Payer: BCBS MT HealthLink |
$26.10
|
| Rate for Payer: BCBS MT Medicare |
$26.10
|
| Rate for Payer: BCBS MT POS |
$27.55
|
| Rate for Payer: BCBS MT Traditional |
$29.00
|
| Rate for Payer: Cash Price |
$26.10
|
| Rate for Payer: Cigna Commercial |
$27.55
|
| Rate for Payer: Cigna Medicare |
$26.10
|
| Rate for Payer: Medicaid All Medicaid |
$26.68
|
| Rate for Payer: Medicare All Medicare |
$20.30
|
| Rate for Payer: Monida Allegiance |
$27.55
|
| Rate for Payer: Monida First Choice Health |
$28.13
|
| Rate for Payer: Monida Montana Health Co-op |
$27.55
|
| Rate for Payer: Monida PacificSource |
$27.55
|
|
|
VENLAFAXINE XR 150MG CAP
|
Facility
|
IP
|
$17.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
3000474
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.90 |
| Max. Negotiated Rate |
$17.00 |
| Rate for Payer: Aetna Commercial |
$16.15
|
| Rate for Payer: Aetna Medicare |
$15.30
|
| Rate for Payer: BCBS MT CHIP |
$15.30
|
| Rate for Payer: BCBS MT Closed Plan Network |
$16.15
|
| Rate for Payer: BCBS MT HealthLink |
$15.30
|
| Rate for Payer: BCBS MT Medicare |
$15.30
|
| Rate for Payer: BCBS MT POS |
$16.15
|
| Rate for Payer: BCBS MT Traditional |
$17.00
|
| Rate for Payer: Cash Price |
$15.30
|
| Rate for Payer: Cigna Commercial |
$16.15
|
| Rate for Payer: Cigna Medicare |
$15.30
|
| Rate for Payer: Medicaid All Medicaid |
$15.64
|
| Rate for Payer: Medicare All Medicare |
$11.90
|
| Rate for Payer: Monida Allegiance |
$16.15
|
| Rate for Payer: Monida First Choice Health |
$16.49
|
| Rate for Payer: Monida Montana Health Co-op |
$16.15
|
| Rate for Payer: Monida PacificSource |
$16.15
|
|
|
VENLAFAXINE XR 150MG CAP
|
Facility
|
OP
|
$17.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
3000474
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.90 |
| Max. Negotiated Rate |
$17.00 |
| Rate for Payer: Aetna Commercial |
$16.15
|
| Rate for Payer: Aetna Medicare |
$15.30
|
| Rate for Payer: BCBS MT CHIP |
$15.30
|
| Rate for Payer: BCBS MT Closed Plan Network |
$16.15
|
| Rate for Payer: BCBS MT HealthLink |
$15.30
|
| Rate for Payer: BCBS MT Medicare |
$15.30
|
| Rate for Payer: BCBS MT POS |
$16.15
|
| Rate for Payer: BCBS MT Traditional |
$17.00
|
| Rate for Payer: Cash Price |
$15.30
|
| Rate for Payer: Cigna Commercial |
$16.15
|
| Rate for Payer: Cigna Medicare |
$15.30
|
| Rate for Payer: Medicaid All Medicaid |
$15.64
|
| Rate for Payer: Medicare All Medicare |
$11.90
|
| Rate for Payer: Monida Allegiance |
$16.15
|
| Rate for Payer: Monida First Choice Health |
$16.49
|
| Rate for Payer: Monida Montana Health Co-op |
$16.15
|
| Rate for Payer: Monida PacificSource |
$16.15
|
|
|
VENLAFAXINE XR 75MG CAP
|
Facility
|
IP
|
$13.50
|
|
|
Service Code
|
NDC 68084070901
|
| Hospital Charge Code |
3007355
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.45 |
| Max. Negotiated Rate |
$13.50 |
| Rate for Payer: Aetna Commercial |
$12.82
|
| Rate for Payer: Aetna Medicare |
$12.15
|
| Rate for Payer: BCBS MT CHIP |
$12.15
|
| Rate for Payer: BCBS MT Closed Plan Network |
$12.82
|
| Rate for Payer: BCBS MT HealthLink |
$12.15
|
| Rate for Payer: BCBS MT Medicare |
$12.15
|
| Rate for Payer: BCBS MT POS |
$12.82
|
| Rate for Payer: BCBS MT Traditional |
$13.50
|
| Rate for Payer: Cash Price |
$12.15
|
| Rate for Payer: Cigna Commercial |
$12.82
|
| Rate for Payer: Cigna Medicare |
$12.15
|
| Rate for Payer: Medicaid All Medicaid |
$12.42
|
| Rate for Payer: Medicare All Medicare |
$9.45
|
| Rate for Payer: Monida Allegiance |
$12.82
|
| Rate for Payer: Monida First Choice Health |
$13.10
|
| Rate for Payer: Monida Montana Health Co-op |
$12.82
|
| Rate for Payer: Monida PacificSource |
$12.82
|
|
