|
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 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
|
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, 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, 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, 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, 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
|
|
|
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
|
|
|
VARICELLA-ZOSTER AB, IGG (096206)
|
Facility
|
IP
|
$69.00
|
|
|
Service Code
|
HCPCS 86787
|
| Hospital Charge Code |
4086787
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$48.30 |
| Max. Negotiated Rate |
$69.00 |
| Rate for Payer: Aetna Commercial |
$65.55
|
| Rate for Payer: Aetna Medicare |
$62.10
|
| Rate for Payer: BCBS MT CHIP |
$62.10
|
| Rate for Payer: BCBS MT Closed Plan Network |
$65.55
|
| Rate for Payer: BCBS MT HealthLink |
$62.10
|
| Rate for Payer: BCBS MT Medicare |
$62.10
|
| Rate for Payer: BCBS MT POS |
$65.55
|
| Rate for Payer: BCBS MT Traditional |
$69.00
|
| Rate for Payer: Cash Price |
$62.10
|
| Rate for Payer: Cigna Commercial |
$65.55
|
| Rate for Payer: Cigna Medicare |
$62.10
|
| Rate for Payer: Medicaid All Medicaid |
$63.48
|
| Rate for Payer: Medicare All Medicare |
$48.30
|
| Rate for Payer: Monida Allegiance |
$65.55
|
| Rate for Payer: Monida First Choice Health |
$66.93
|
| Rate for Payer: Monida Montana Health Co-op |
$65.55
|
| Rate for Payer: Monida PacificSource |
$65.55
|
|
|
VARICELLA-ZOSTER AB, IGG (096206)
|
Facility
|
OP
|
$69.00
|
|
|
Service Code
|
HCPCS 86787
|
| Hospital Charge Code |
4086787
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$48.30 |
| Max. Negotiated Rate |
$69.00 |
| Rate for Payer: Aetna Commercial |
$65.55
|
| Rate for Payer: Aetna Medicare |
$62.10
|
| Rate for Payer: BCBS MT CHIP |
$62.10
|
| Rate for Payer: BCBS MT Closed Plan Network |
$65.55
|
| Rate for Payer: BCBS MT HealthLink |
$62.10
|
| Rate for Payer: BCBS MT Medicare |
$62.10
|
| Rate for Payer: BCBS MT POS |
$65.55
|
| Rate for Payer: BCBS MT Traditional |
$69.00
|
| Rate for Payer: Cash Price |
$62.10
|
| Rate for Payer: Cigna Commercial |
$65.55
|
| Rate for Payer: Cigna Medicare |
$62.10
|
| Rate for Payer: Medicaid All Medicaid |
$63.48
|
| Rate for Payer: Medicare All Medicare |
$48.30
|
| Rate for Payer: Monida Allegiance |
$65.55
|
| Rate for Payer: Monida First Choice Health |
$66.93
|
| Rate for Payer: Monida Montana Health Co-op |
$65.55
|
| Rate for Payer: Monida PacificSource |
$65.55
|
|
|
VARICELLA ZOSTER NAAT
|
Facility
|
IP
|
$104.00
|
|
|
Service Code
|
HCPCS 87798
|
| Hospital Charge Code |
4087923
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$72.80 |
| Max. Negotiated Rate |
$104.00 |
| Rate for Payer: Aetna Commercial |
$98.80
|
| Rate for Payer: Aetna Medicare |
$93.60
|
| Rate for Payer: BCBS MT CHIP |
$93.60
|
| Rate for Payer: BCBS MT Closed Plan Network |
$98.80
|
| Rate for Payer: BCBS MT HealthLink |
$93.60
|
| Rate for Payer: BCBS MT Medicare |
$93.60
|
| Rate for Payer: BCBS MT POS |
$98.80
|
| Rate for Payer: BCBS MT Traditional |
$104.00
|
| Rate for Payer: Cash Price |
$93.60
|
| Rate for Payer: Cigna Commercial |
$98.80
|
| Rate for Payer: Cigna Medicare |
$93.60
|
| Rate for Payer: Medicaid All Medicaid |
$95.68
|
| Rate for Payer: Medicare All Medicare |
$72.80
|
| Rate for Payer: Monida Allegiance |
$98.80
|
| Rate for Payer: Monida First Choice Health |
$100.88
|
| Rate for Payer: Monida Montana Health Co-op |
$98.80
|
| Rate for Payer: Monida PacificSource |
$98.80
|
|
|
VARICELLA ZOSTER NAAT
|
Facility
|
OP
|
$104.00
|
|
|
Service Code
|
HCPCS 87798
|
| Hospital Charge Code |
4087923
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$72.80 |
| Max. Negotiated Rate |
$104.00 |
| Rate for Payer: Aetna Commercial |
$98.80
|
| Rate for Payer: Aetna Medicare |
$93.60
|
| Rate for Payer: BCBS MT CHIP |
$93.60
|
| Rate for Payer: BCBS MT Closed Plan Network |
$98.80
|
| Rate for Payer: BCBS MT HealthLink |
$93.60
|
| Rate for Payer: BCBS MT Medicare |
$93.60
|
| Rate for Payer: BCBS MT POS |
$98.80
|
| Rate for Payer: BCBS MT Traditional |
$104.00
|
| Rate for Payer: Cash Price |
$93.60
|
| Rate for Payer: Cigna Commercial |
$98.80
|
| Rate for Payer: Cigna Medicare |
$93.60
|
| Rate for Payer: Medicaid All Medicaid |
$95.68
|
| Rate for Payer: Medicare All Medicare |
$72.80
|
| Rate for Payer: Monida Allegiance |
$98.80
|
| Rate for Payer: Monida First Choice Health |
$100.88
|
| Rate for Payer: Monida Montana Health Co-op |
$98.80
|
| Rate for Payer: Monida PacificSource |
$98.80
|
|
|
.VENIPUNCTURE
|
Facility
|
OP
|
$31.00
|
|
|
Service Code
|
HCPCS 36415
|
| Hospital Charge Code |
4036415
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$21.70 |
| Max. Negotiated Rate |
$31.00 |
| Rate for Payer: Aetna Commercial |
$29.45
|
| Rate for Payer: Aetna Medicare |
$27.90
|
| Rate for Payer: BCBS MT CHIP |
$27.90
|
| Rate for Payer: BCBS MT Closed Plan Network |
$29.45
|
| Rate for Payer: BCBS MT HealthLink |
$27.90
|
| Rate for Payer: BCBS MT Medicare |
$27.90
|
| Rate for Payer: BCBS MT POS |
$29.45
|
| Rate for Payer: BCBS MT Traditional |
$31.00
|
| Rate for Payer: Cash Price |
$27.90
|
| Rate for Payer: Cigna Commercial |
$29.45
|
| Rate for Payer: Cigna Medicare |
$27.90
|
| Rate for Payer: Medicaid All Medicaid |
$28.52
|
| Rate for Payer: Medicare All Medicare |
$21.70
|
| Rate for Payer: Monida Allegiance |
$29.45
|
| Rate for Payer: Monida First Choice Health |
$30.07
|
| Rate for Payer: Monida Montana Health Co-op |
$29.45
|
| Rate for Payer: Monida PacificSource |
$29.45
|
|
|
.VENIPUNCTURE
|
Facility
|
IP
|
$31.00
|
|
|
Service Code
|
HCPCS 36415
|
| Hospital Charge Code |
4036415
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$21.70 |
| Max. Negotiated Rate |
$31.00 |
| Rate for Payer: Aetna Commercial |
$29.45
|
| Rate for Payer: Aetna Medicare |
$27.90
|
| Rate for Payer: BCBS MT CHIP |
$27.90
|
| Rate for Payer: BCBS MT Closed Plan Network |
$29.45
|
| Rate for Payer: BCBS MT HealthLink |
$27.90
|
| Rate for Payer: BCBS MT Medicare |
$27.90
|
| Rate for Payer: BCBS MT POS |
$29.45
|
| Rate for Payer: BCBS MT Traditional |
$31.00
|
| Rate for Payer: Cash Price |
$27.90
|
| Rate for Payer: Cigna Commercial |
$29.45
|
| Rate for Payer: Cigna Medicare |
$27.90
|
| Rate for Payer: Medicaid All Medicaid |
$28.52
|
| Rate for Payer: Medicare All Medicare |
$21.70
|
| Rate for Payer: Monida Allegiance |
$29.45
|
| Rate for Payer: Monida First Choice Health |
$30.07
|
| Rate for Payer: Monida Montana Health Co-op |
$29.45
|
| Rate for Payer: Monida PacificSource |
$29.45
|
|
|
VENLAFAXINE TAB [75 MG] NF
|
Facility
|
IP
|
$8.00
|
|
|
Service Code
|
NDC 68084085611
|
| Hospital Charge Code |
3000583
|
|
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
|
|
|
VENLAFAXINE TAB [75 MG] NF
|
Facility
|
OP
|
$8.00
|
|
|
Service Code
|
NDC 68084085611
|
| Hospital Charge Code |
3000583
|
|
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
|
|
|
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 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 75MG CAP NF
|
Facility
|
OP
|
$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
|
|
|
VENLAFAXINE XR 75MG CAP NF
|
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
|
|
|
VENLAFAXINE XR CAP [37.5 MG]
|
Facility
|
IP
|
$13.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
3000475
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.10 |
| Max. Negotiated Rate |
$13.00 |
| Rate for Payer: Aetna Commercial |
$12.35
|
| Rate for Payer: Aetna Medicare |
$11.70
|
| Rate for Payer: BCBS MT CHIP |
$11.70
|
| Rate for Payer: BCBS MT Closed Plan Network |
$12.35
|
| Rate for Payer: BCBS MT HealthLink |
$11.70
|
| Rate for Payer: BCBS MT Medicare |
$11.70
|
| Rate for Payer: BCBS MT POS |
$12.35
|
| Rate for Payer: BCBS MT Traditional |
$13.00
|
| Rate for Payer: Cash Price |
$11.70
|
| Rate for Payer: Cigna Commercial |
$12.35
|
| Rate for Payer: Cigna Medicare |
$11.70
|
| Rate for Payer: Medicaid All Medicaid |
$11.96
|
| Rate for Payer: Medicare All Medicare |
$9.10
|
| Rate for Payer: Monida Allegiance |
$12.35
|
| Rate for Payer: Monida First Choice Health |
$12.61
|
| Rate for Payer: Monida Montana Health Co-op |
$12.35
|
| Rate for Payer: Monida PacificSource |
$12.35
|
|
|
VENLAFAXINE XR CAP [37.5 MG]
|
Facility
|
OP
|
$13.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
3000475
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.10 |
| Max. Negotiated Rate |
$13.00 |
| Rate for Payer: Aetna Commercial |
$12.35
|
| Rate for Payer: Aetna Medicare |
$11.70
|
| Rate for Payer: BCBS MT CHIP |
$11.70
|
| Rate for Payer: BCBS MT Closed Plan Network |
$12.35
|
| Rate for Payer: BCBS MT HealthLink |
$11.70
|
| Rate for Payer: BCBS MT Medicare |
$11.70
|
| Rate for Payer: BCBS MT POS |
$12.35
|
| Rate for Payer: BCBS MT Traditional |
$13.00
|
| Rate for Payer: Cash Price |
$11.70
|
| Rate for Payer: Cigna Commercial |
$12.35
|
| Rate for Payer: Cigna Medicare |
$11.70
|
| Rate for Payer: Medicaid All Medicaid |
$11.96
|
| Rate for Payer: Medicare All Medicare |
$9.10
|
| Rate for Payer: Monida Allegiance |
$12.35
|
| Rate for Payer: Monida First Choice Health |
$12.61
|
| Rate for Payer: Monida Montana Health Co-op |
$12.35
|
| Rate for Payer: Monida PacificSource |
$12.35
|
|
|
VERAPAMIL ER TAB [240 MG] NF
|
Facility
|
OP
|
$8.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
3000476
|
|
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
|
|
|
VERAPAMIL ER TAB [240 MG] NF
|
Facility
|
IP
|
$8.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
3000476
|
|
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
|
|
