|
PROFEXR CTA THORACIC AORTA W OR W/O CONT
|
Professional
|
Both
|
$344.00
|
|
|
Service Code
|
CPT 75635
|
| Hospital Charge Code |
50002248
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$240.80 |
| Max. Negotiated Rate |
$333.68 |
| Rate for Payer: Aetna Commercial |
$326.80
|
| Rate for Payer: Aetna Medicare |
$309.60
|
| Rate for Payer: Cash Price |
$309.60
|
| Rate for Payer: Medicaid All Medicaid |
$316.48
|
| Rate for Payer: Medicare All Medicare |
$240.80
|
| Rate for Payer: Monida Allegiance |
$326.80
|
| Rate for Payer: Monida First Choice Health |
$333.68
|
| Rate for Payer: Monida Montana Health Co-op |
$326.80
|
| Rate for Payer: Monida PacificSource |
$326.80
|
|
|
PROGESTERONE (004317)
|
Facility
|
OP
|
$90.00
|
|
|
Service Code
|
CPT 84144
|
| Hospital Charge Code |
4084144
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$63.00 |
| Max. Negotiated Rate |
$90.00 |
| Rate for Payer: Aetna Commercial |
$85.50
|
| Rate for Payer: Aetna Medicare |
$81.00
|
| Rate for Payer: BCBS MT CHIP |
$81.00
|
| Rate for Payer: BCBS MT Closed Plan Network |
$85.50
|
| Rate for Payer: BCBS MT HealthLink |
$81.00
|
| Rate for Payer: BCBS MT Medicare |
$81.00
|
| Rate for Payer: BCBS MT POS |
$85.50
|
| Rate for Payer: BCBS MT Traditional |
$90.00
|
| Rate for Payer: Cash Price |
$81.00
|
| Rate for Payer: Cigna Commercial |
$85.50
|
| Rate for Payer: Cigna Medicare |
$81.00
|
| Rate for Payer: Medicaid All Medicaid |
$82.80
|
| Rate for Payer: Medicare All Medicare |
$63.00
|
| Rate for Payer: Monida Allegiance |
$85.50
|
| Rate for Payer: Monida First Choice Health |
$87.30
|
| Rate for Payer: Monida Montana Health Co-op |
$85.50
|
| Rate for Payer: Monida PacificSource |
$85.50
|
|
|
PROGESTERONE (004317)
|
Facility
|
IP
|
$90.00
|
|
|
Service Code
|
CPT 84144
|
| Hospital Charge Code |
4084144
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$63.00 |
| Max. Negotiated Rate |
$90.00 |
| Rate for Payer: Aetna Commercial |
$85.50
|
| Rate for Payer: Aetna Medicare |
$81.00
|
| Rate for Payer: BCBS MT CHIP |
$81.00
|
| Rate for Payer: BCBS MT Closed Plan Network |
$85.50
|
| Rate for Payer: BCBS MT HealthLink |
$81.00
|
| Rate for Payer: BCBS MT Medicare |
$81.00
|
| Rate for Payer: BCBS MT POS |
$85.50
|
| Rate for Payer: BCBS MT Traditional |
$90.00
|
| Rate for Payer: Cash Price |
$81.00
|
| Rate for Payer: Cigna Commercial |
$85.50
|
| Rate for Payer: Cigna Medicare |
$81.00
|
| Rate for Payer: Medicaid All Medicaid |
$82.80
|
| Rate for Payer: Medicare All Medicare |
$63.00
|
| Rate for Payer: Monida Allegiance |
$85.50
|
| Rate for Payer: Monida First Choice Health |
$87.30
|
| Rate for Payer: Monida Montana Health Co-op |
$85.50
|
| Rate for Payer: Monida PacificSource |
$85.50
|
|
|
PROINSULIN
|
Facility
|
IP
|
$115.00
|
|
|
Service Code
|
CPT 84206
|
| Hospital Charge Code |
4087943
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$80.50 |
| Max. Negotiated Rate |
$115.00 |
| Rate for Payer: Aetna Commercial |
$109.25
|
| Rate for Payer: Aetna Medicare |
$103.50
|
| Rate for Payer: BCBS MT CHIP |
$103.50
|
| Rate for Payer: BCBS MT Closed Plan Network |
$109.25
|
| Rate for Payer: BCBS MT HealthLink |
$103.50
|
| Rate for Payer: BCBS MT Medicare |
$103.50
|
| Rate for Payer: BCBS MT POS |
$109.25
|
| Rate for Payer: BCBS MT Traditional |
$115.00
|
| Rate for Payer: Cash Price |
$103.50
|
| Rate for Payer: Cigna Commercial |
$109.25
|
| Rate for Payer: Cigna Medicare |
$103.50
|
| Rate for Payer: Medicaid All Medicaid |
$105.80
|
| Rate for Payer: Medicare All Medicare |
$80.50
|
| Rate for Payer: Monida Allegiance |
$109.25
|
| Rate for Payer: Monida First Choice Health |
$111.55
|
| Rate for Payer: Monida Montana Health Co-op |
$109.25
|
| Rate for Payer: Monida PacificSource |
$109.25
|
|
|
PROINSULIN
|
Facility
|
OP
|
$115.00
|
|
|
Service Code
|
CPT 84206
|
| Hospital Charge Code |
4087943
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$80.50 |
| Max. Negotiated Rate |
$115.00 |
| Rate for Payer: Aetna Commercial |
$109.25
|
| Rate for Payer: Aetna Medicare |
$103.50
|
| Rate for Payer: BCBS MT CHIP |
$103.50
|
| Rate for Payer: BCBS MT Closed Plan Network |
$109.25
|
| Rate for Payer: BCBS MT HealthLink |
$103.50
|
| Rate for Payer: BCBS MT Medicare |
$103.50
|
| Rate for Payer: BCBS MT POS |
$109.25
|
| Rate for Payer: BCBS MT Traditional |
$115.00
|
| Rate for Payer: Cash Price |
$103.50
|
| Rate for Payer: Cigna Commercial |
$109.25
|
| Rate for Payer: Cigna Medicare |
$103.50
|
| Rate for Payer: Medicaid All Medicaid |
$105.80
|
| Rate for Payer: Medicare All Medicare |
$80.50
|
| Rate for Payer: Monida Allegiance |
$109.25
|
| Rate for Payer: Monida First Choice Health |
$111.55
|
| Rate for Payer: Monida Montana Health Co-op |
$109.25
|
| Rate for Payer: Monida PacificSource |
$109.25
|
|
|
PROLACTIN (004465)
|
Facility
|
IP
|
$78.00
|
|
|
Service Code
|
CPT 84146
|
| Hospital Charge Code |
4084146
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$54.60 |
| Max. Negotiated Rate |
$78.00 |
| Rate for Payer: Aetna Commercial |
$74.10
|
| Rate for Payer: Aetna Medicare |
$70.20
|
| Rate for Payer: BCBS MT CHIP |
$70.20
|
| Rate for Payer: BCBS MT Closed Plan Network |
$74.10
|
| Rate for Payer: BCBS MT HealthLink |
$70.20
|
| Rate for Payer: BCBS MT Medicare |
$70.20
|
| Rate for Payer: BCBS MT POS |
$74.10
|
| Rate for Payer: BCBS MT Traditional |
$78.00
|
| Rate for Payer: Cash Price |
$70.20
|
| Rate for Payer: Cigna Commercial |
$74.10
|
| Rate for Payer: Cigna Medicare |
$70.20
|
| Rate for Payer: Medicaid All Medicaid |
$71.76
|
| Rate for Payer: Medicare All Medicare |
$54.60
|
| Rate for Payer: Monida Allegiance |
$74.10
|
| Rate for Payer: Monida First Choice Health |
$75.66
|
| Rate for Payer: Monida Montana Health Co-op |
$74.10
|
| Rate for Payer: Monida PacificSource |
$74.10
|
|
|
PROLACTIN (004465)
|
Facility
|
OP
|
$78.00
|
|
|
Service Code
|
CPT 84146
|
| Hospital Charge Code |
4084146
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$54.60 |
| Max. Negotiated Rate |
$78.00 |
| Rate for Payer: Aetna Commercial |
$74.10
|
| Rate for Payer: Aetna Medicare |
$70.20
|
| Rate for Payer: BCBS MT CHIP |
$70.20
|
| Rate for Payer: BCBS MT Closed Plan Network |
$74.10
|
| Rate for Payer: BCBS MT HealthLink |
$70.20
|
| Rate for Payer: BCBS MT Medicare |
$70.20
|
| Rate for Payer: BCBS MT POS |
$74.10
|
| Rate for Payer: BCBS MT Traditional |
$78.00
|
| Rate for Payer: Cash Price |
$70.20
|
| Rate for Payer: Cigna Commercial |
$74.10
|
| Rate for Payer: Cigna Medicare |
$70.20
|
| Rate for Payer: Medicaid All Medicaid |
$71.76
|
| Rate for Payer: Medicare All Medicare |
$54.60
|
| Rate for Payer: Monida Allegiance |
$74.10
|
| Rate for Payer: Monida First Choice Health |
$75.66
|
| Rate for Payer: Monida Montana Health Co-op |
$74.10
|
| Rate for Payer: Monida PacificSource |
$74.10
|
|
|
PROLONGED CLOT TIME REFLEX PROFILE
|
Facility
|
OP
|
$250.00
|
|
|
Service Code
|
CPT 85390
|
| Hospital Charge Code |
4088056
|
|
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
|
|
|
PROLONGED CLOT TIME REFLEX PROFILE
|
Facility
|
IP
|
$250.00
|
|
|
Service Code
|
CPT 85390
|
| Hospital Charge Code |
4088056
|
|
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
|
|
|
PROLONGED OP E/M SERV-EXCEEDED 15 MIN
|
Facility
|
IP
|
$80.00
|
|
|
Service Code
|
CPT 99417
|
| Hospital Charge Code |
8099417
|
|
Hospital Revenue Code
|
521
|
| 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
|
|
|
PROLONGED OP E/M SERV-EXCEEDED 15 MIN
|
Facility
|
OP
|
$80.00
|
|
|
Service Code
|
CPT 99417
|
| Hospital Charge Code |
8099417
|
|
Hospital Revenue Code
|
521
|
| 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
|
|
|
PROLONGED OV/OP E/M-EA ADDI 15 MIN-G2212
|
Facility
|
IP
|
$80.00
|
|
|
Service Code
|
HCPCS G2212
|
| Hospital Charge Code |
8002212
|
|
Hospital Revenue Code
|
521
|
| 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
|
|
|
PROLONGED OV/OP E/M-EA ADDI 15 MIN-G2212
|
Facility
|
OP
|
$80.00
|
|
|
Service Code
|
HCPCS G2212
|
| Hospital Charge Code |
8002212
|
|
Hospital Revenue Code
|
521
|
| 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
|
|
|
PROMETHAZINE HCL TAB [25 MG]
|
Facility
|
IP
|
$8.00
|
|
|
Service Code
|
HCPCS Q0169
|
| Hospital Charge Code |
3007332
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.60 |
| Max. Negotiated Rate |
$8.00 |
| Rate for Payer: Aetna Commercial |
$7.60
|
| Rate for Payer: Aetna Medicare |
$7.20
|
| Rate for Payer: BCBS MT CHIP |
$7.20
|
| Rate for Payer: BCBS MT Closed Plan Network |
$7.60
|
| Rate for Payer: BCBS MT HealthLink |
$7.20
|
| Rate for Payer: BCBS MT Medicare |
$7.20
|
| Rate for Payer: BCBS MT POS |
$7.60
|
| Rate for Payer: BCBS MT Traditional |
$8.00
|
| Rate for Payer: Cash Price |
$7.20
|
| Rate for Payer: Cigna Commercial |
$7.60
|
| Rate for Payer: Cigna Medicare |
$7.20
|
| Rate for Payer: Medicaid All Medicaid |
$7.36
|
| Rate for Payer: Medicare All Medicare |
$5.60
|
| Rate for Payer: Monida Allegiance |
$7.60
|
| Rate for Payer: Monida First Choice Health |
$7.76
|
| Rate for Payer: Monida Montana Health Co-op |
$7.60
|
| Rate for Payer: Monida PacificSource |
$7.60
|
|
|
PROMETHAZINE HCL TAB [25 MG]
|
Facility
|
OP
|
$8.00
|
|
|
Service Code
|
HCPCS Q0169
|
| Hospital Charge Code |
3007332
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.60 |
| Max. Negotiated Rate |
$8.00 |
| Rate for Payer: Aetna Commercial |
$7.60
|
| Rate for Payer: Aetna Medicare |
$7.20
|
| Rate for Payer: BCBS MT CHIP |
$7.20
|
| Rate for Payer: BCBS MT Closed Plan Network |
$7.60
|
| Rate for Payer: BCBS MT HealthLink |
$7.20
|
| Rate for Payer: BCBS MT Medicare |
$7.20
|
| Rate for Payer: BCBS MT POS |
$7.60
|
| Rate for Payer: BCBS MT Traditional |
$8.00
|
| Rate for Payer: Cash Price |
$7.20
|
| Rate for Payer: Cigna Commercial |
$7.60
|
| Rate for Payer: Cigna Medicare |
$7.20
|
| Rate for Payer: Medicaid All Medicaid |
$7.36
|
| Rate for Payer: Medicare All Medicare |
$5.60
|
| Rate for Payer: Monida Allegiance |
$7.60
|
| Rate for Payer: Monida First Choice Health |
$7.76
|
| Rate for Payer: Monida Montana Health Co-op |
$7.60
|
| Rate for Payer: Monida PacificSource |
$7.60
|
|
|
PROMETHAZINE INJ [25 MG/ML]
|
Facility
|
IP
|
$8.00
|
|
|
Service Code
|
HCPCS J2550
|
| Hospital Charge Code |
3000405
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.60 |
| Max. Negotiated Rate |
$8.00 |
| Rate for Payer: Aetna Commercial |
$7.60
|
| Rate for Payer: Aetna Medicare |
$7.20
|
| Rate for Payer: BCBS MT CHIP |
$7.20
|
| Rate for Payer: BCBS MT Closed Plan Network |
$7.60
|
| Rate for Payer: BCBS MT HealthLink |
$7.20
|
| Rate for Payer: BCBS MT Medicare |
$7.20
|
| Rate for Payer: BCBS MT POS |
$7.60
|
| Rate for Payer: BCBS MT Traditional |
$8.00
|
| Rate for Payer: Cash Price |
$7.20
|
| Rate for Payer: Cigna Commercial |
$7.60
|
| Rate for Payer: Cigna Medicare |
$7.20
|
| Rate for Payer: Medicaid All Medicaid |
$7.36
|
| Rate for Payer: Medicare All Medicare |
$5.60
|
| Rate for Payer: Monida Allegiance |
$7.60
|
| Rate for Payer: Monida First Choice Health |
$7.76
|
| Rate for Payer: Monida Montana Health Co-op |
$7.60
|
| Rate for Payer: Monida PacificSource |
$7.60
|
|
|
PROMETHAZINE INJ [25 MG/ML]
|
Facility
|
IP
|
$8.00
|
|
|
Service Code
|
HCPCS J2250
|
| Hospital Charge Code |
3000562
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.60 |
| Max. Negotiated Rate |
$8.00 |
| Rate for Payer: Aetna Commercial |
$7.60
|
| Rate for Payer: Aetna Medicare |
$7.20
|
| Rate for Payer: BCBS MT CHIP |
$7.20
|
| Rate for Payer: BCBS MT Closed Plan Network |
$7.60
|
| Rate for Payer: BCBS MT HealthLink |
$7.20
|
| Rate for Payer: BCBS MT Medicare |
$7.20
|
| Rate for Payer: BCBS MT POS |
$7.60
|
| Rate for Payer: BCBS MT Traditional |
$8.00
|
| Rate for Payer: Cash Price |
$7.20
|
| Rate for Payer: Cigna Commercial |
$7.60
|
| Rate for Payer: Cigna Medicare |
$7.20
|
| Rate for Payer: Medicaid All Medicaid |
$7.36
|
| Rate for Payer: Medicare All Medicare |
$5.60
|
| Rate for Payer: Monida Allegiance |
$7.60
|
| Rate for Payer: Monida First Choice Health |
$7.76
|
| Rate for Payer: Monida Montana Health Co-op |
$7.60
|
| Rate for Payer: Monida PacificSource |
$7.60
|
|
|
PROMETHAZINE INJ [25 MG/ML]
|
Facility
|
OP
|
$8.00
|
|
|
Service Code
|
HCPCS J2550
|
| Hospital Charge Code |
3000405
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.60 |
| Max. Negotiated Rate |
$8.00 |
| Rate for Payer: Aetna Commercial |
$7.60
|
| Rate for Payer: Aetna Medicare |
$7.20
|
| Rate for Payer: BCBS MT CHIP |
$7.20
|
| Rate for Payer: BCBS MT Closed Plan Network |
$7.60
|
| Rate for Payer: BCBS MT HealthLink |
$7.20
|
| Rate for Payer: BCBS MT Medicare |
$7.20
|
| Rate for Payer: BCBS MT POS |
$7.60
|
| Rate for Payer: BCBS MT Traditional |
$8.00
|
| Rate for Payer: Cash Price |
$7.20
|
| Rate for Payer: Cigna Commercial |
$7.60
|
| Rate for Payer: Cigna Medicare |
$7.20
|
| Rate for Payer: Medicaid All Medicaid |
$7.36
|
| Rate for Payer: Medicare All Medicare |
$5.60
|
| Rate for Payer: Monida Allegiance |
$7.60
|
| Rate for Payer: Monida First Choice Health |
$7.76
|
| Rate for Payer: Monida Montana Health Co-op |
$7.60
|
| Rate for Payer: Monida PacificSource |
$7.60
|
|
|
PROMETHAZINE INJ [25 MG/ML]
|
Facility
|
OP
|
$8.00
|
|
|
Service Code
|
HCPCS J2250
|
| Hospital Charge Code |
3000562
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.60 |
| Max. Negotiated Rate |
$8.00 |
| Rate for Payer: Aetna Commercial |
$7.60
|
| Rate for Payer: Aetna Medicare |
$7.20
|
| Rate for Payer: BCBS MT CHIP |
$7.20
|
| Rate for Payer: BCBS MT Closed Plan Network |
$7.60
|
| Rate for Payer: BCBS MT HealthLink |
$7.20
|
| Rate for Payer: BCBS MT Medicare |
$7.20
|
| Rate for Payer: BCBS MT POS |
$7.60
|
| Rate for Payer: BCBS MT Traditional |
$8.00
|
| Rate for Payer: Cash Price |
$7.20
|
| Rate for Payer: Cigna Commercial |
$7.60
|
| Rate for Payer: Cigna Medicare |
$7.20
|
| Rate for Payer: Medicaid All Medicaid |
$7.36
|
| Rate for Payer: Medicare All Medicare |
$5.60
|
| Rate for Payer: Monida Allegiance |
$7.60
|
| Rate for Payer: Monida First Choice Health |
$7.76
|
| Rate for Payer: Monida Montana Health Co-op |
$7.60
|
| Rate for Payer: Monida PacificSource |
$7.60
|
|
|
PROMETHAZINE SUPPOSITORY 12.5MG
|
Facility
|
OP
|
$56.70
|
|
| Hospital Charge Code |
3007329
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$39.69 |
| Max. Negotiated Rate |
$56.70 |
| Rate for Payer: Aetna Commercial |
$53.87
|
| Rate for Payer: Aetna Medicare |
$51.03
|
| Rate for Payer: BCBS MT CHIP |
$51.03
|
| Rate for Payer: BCBS MT Closed Plan Network |
$53.87
|
| Rate for Payer: BCBS MT HealthLink |
$51.03
|
| Rate for Payer: BCBS MT Medicare |
$51.03
|
| Rate for Payer: BCBS MT POS |
$53.87
|
| Rate for Payer: BCBS MT Traditional |
$56.70
|
| Rate for Payer: Cash Price |
$51.03
|
| Rate for Payer: Cigna Commercial |
$53.87
|
| Rate for Payer: Cigna Medicare |
$51.03
|
| Rate for Payer: Medicaid All Medicaid |
$52.16
|
| Rate for Payer: Medicare All Medicare |
$39.69
|
| Rate for Payer: Monida Allegiance |
$53.87
|
| Rate for Payer: Monida First Choice Health |
$55.00
|
| Rate for Payer: Monida Montana Health Co-op |
$53.87
|
| Rate for Payer: Monida PacificSource |
$53.87
|
|
|
PROMETHAZINE SUPPOSITORY 12.5MG
|
Facility
|
IP
|
$56.70
|
|
| Hospital Charge Code |
3007329
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$39.69 |
| Max. Negotiated Rate |
$56.70 |
| Rate for Payer: Aetna Commercial |
$53.87
|
| Rate for Payer: Aetna Medicare |
$51.03
|
| Rate for Payer: BCBS MT CHIP |
$51.03
|
| Rate for Payer: BCBS MT Closed Plan Network |
$53.87
|
| Rate for Payer: BCBS MT HealthLink |
$51.03
|
| Rate for Payer: BCBS MT Medicare |
$51.03
|
| Rate for Payer: BCBS MT POS |
$53.87
|
| Rate for Payer: BCBS MT Traditional |
$56.70
|
| Rate for Payer: Cash Price |
$51.03
|
| Rate for Payer: Cigna Commercial |
$53.87
|
| Rate for Payer: Cigna Medicare |
$51.03
|
| Rate for Payer: Medicaid All Medicaid |
$52.16
|
| Rate for Payer: Medicare All Medicare |
$39.69
|
| Rate for Payer: Monida Allegiance |
$53.87
|
| Rate for Payer: Monida First Choice Health |
$55.00
|
| Rate for Payer: Monida Montana Health Co-op |
$53.87
|
| Rate for Payer: Monida PacificSource |
$53.87
|
|
|
PROMETHAZINE TAB [25 MG]
|
Facility
|
IP
|
$8.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
3000406
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.60 |
| Max. Negotiated Rate |
$8.00 |
| Rate for Payer: Aetna Commercial |
$7.60
|
| Rate for Payer: Aetna Medicare |
$7.20
|
| Rate for Payer: BCBS MT CHIP |
$7.20
|
| Rate for Payer: BCBS MT Closed Plan Network |
$7.60
|
| Rate for Payer: BCBS MT HealthLink |
$7.20
|
| Rate for Payer: BCBS MT Medicare |
$7.20
|
| Rate for Payer: BCBS MT POS |
$7.60
|
| Rate for Payer: BCBS MT Traditional |
$8.00
|
| Rate for Payer: Cash Price |
$7.20
|
| Rate for Payer: Cigna Commercial |
$7.60
|
| Rate for Payer: Cigna Medicare |
$7.20
|
| Rate for Payer: Medicaid All Medicaid |
$7.36
|
| Rate for Payer: Medicare All Medicare |
$5.60
|
| Rate for Payer: Monida Allegiance |
$7.60
|
| Rate for Payer: Monida First Choice Health |
$7.76
|
| Rate for Payer: Monida Montana Health Co-op |
$7.60
|
| Rate for Payer: Monida PacificSource |
$7.60
|
|
|
PROMETHAZINE TAB [25 MG]
|
Facility
|
OP
|
$8.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
3000406
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.60 |
| Max. Negotiated Rate |
$8.00 |
| Rate for Payer: Aetna Commercial |
$7.60
|
| Rate for Payer: Aetna Medicare |
$7.20
|
| Rate for Payer: BCBS MT CHIP |
$7.20
|
| Rate for Payer: BCBS MT Closed Plan Network |
$7.60
|
| Rate for Payer: BCBS MT HealthLink |
$7.20
|
| Rate for Payer: BCBS MT Medicare |
$7.20
|
| Rate for Payer: BCBS MT POS |
$7.60
|
| Rate for Payer: BCBS MT Traditional |
$8.00
|
| Rate for Payer: Cash Price |
$7.20
|
| Rate for Payer: Cigna Commercial |
$7.60
|
| Rate for Payer: Cigna Medicare |
$7.20
|
| Rate for Payer: Medicaid All Medicaid |
$7.36
|
| Rate for Payer: Medicare All Medicare |
$5.60
|
| Rate for Payer: Monida Allegiance |
$7.60
|
| Rate for Payer: Monida First Choice Health |
$7.76
|
| Rate for Payer: Monida Montana Health Co-op |
$7.60
|
| Rate for Payer: Monida PacificSource |
$7.60
|
|
|
PROPAFENONE TAB [150 MG] NF
|
Facility
|
IP
|
$8.00
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
3007297
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.60 |
| Max. Negotiated Rate |
$8.00 |
| Rate for Payer: Aetna Commercial |
$7.60
|
| Rate for Payer: Aetna Medicare |
$7.20
|
| Rate for Payer: BCBS MT CHIP |
$7.20
|
| Rate for Payer: BCBS MT Closed Plan Network |
$7.60
|
| Rate for Payer: BCBS MT HealthLink |
$7.20
|
| Rate for Payer: BCBS MT Medicare |
$7.20
|
| Rate for Payer: BCBS MT POS |
$7.60
|
| Rate for Payer: BCBS MT Traditional |
$8.00
|
| Rate for Payer: Cash Price |
$7.20
|
| Rate for Payer: Cigna Commercial |
$7.60
|
| Rate for Payer: Cigna Medicare |
$7.20
|
| Rate for Payer: Medicaid All Medicaid |
$7.36
|
| Rate for Payer: Medicare All Medicare |
$5.60
|
| Rate for Payer: Monida Allegiance |
$7.60
|
| Rate for Payer: Monida First Choice Health |
$7.76
|
| Rate for Payer: Monida Montana Health Co-op |
$7.60
|
| Rate for Payer: Monida PacificSource |
$7.60
|
|
|
PROPAFENONE TAB [150 MG] NF
|
Facility
|
OP
|
$8.00
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
3007297
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.60 |
| Max. Negotiated Rate |
$8.00 |
| Rate for Payer: Aetna Commercial |
$7.60
|
| Rate for Payer: Aetna Medicare |
$7.20
|
| Rate for Payer: BCBS MT CHIP |
$7.20
|
| Rate for Payer: BCBS MT Closed Plan Network |
$7.60
|
| Rate for Payer: BCBS MT HealthLink |
$7.20
|
| Rate for Payer: BCBS MT Medicare |
$7.20
|
| Rate for Payer: BCBS MT POS |
$7.60
|
| Rate for Payer: BCBS MT Traditional |
$8.00
|
| Rate for Payer: Cash Price |
$7.20
|
| Rate for Payer: Cigna Commercial |
$7.60
|
| Rate for Payer: Cigna Medicare |
$7.20
|
| Rate for Payer: Medicaid All Medicaid |
$7.36
|
| Rate for Payer: Medicare All Medicare |
$5.60
|
| Rate for Payer: Monida Allegiance |
$7.60
|
| Rate for Payer: Monida First Choice Health |
$7.76
|
| Rate for Payer: Monida Montana Health Co-op |
$7.60
|
| Rate for Payer: Monida PacificSource |
$7.60
|
|
