|
CCP AB, IGG/IGA (164914)
|
Facility
|
IP
|
$53.00
|
|
|
Service Code
|
HCPCS 86200
|
| Hospital Charge Code |
4086200
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$37.10 |
| Max. Negotiated Rate |
$53.00 |
| Rate for Payer: Aetna Commercial |
$50.35
|
| Rate for Payer: Aetna Medicare |
$47.70
|
| Rate for Payer: BCBS MT CHIP |
$47.70
|
| Rate for Payer: BCBS MT Closed Plan Network |
$50.35
|
| Rate for Payer: BCBS MT HealthLink |
$47.70
|
| Rate for Payer: BCBS MT Medicare |
$47.70
|
| Rate for Payer: BCBS MT POS |
$50.35
|
| Rate for Payer: BCBS MT Traditional |
$53.00
|
| Rate for Payer: Cash Price |
$47.70
|
| Rate for Payer: Cigna Commercial |
$50.35
|
| Rate for Payer: Cigna Medicare |
$47.70
|
| Rate for Payer: Medicaid All Medicaid |
$48.76
|
| Rate for Payer: Medicare All Medicare |
$37.10
|
| Rate for Payer: Monida Allegiance |
$50.35
|
| Rate for Payer: Monida First Choice Health |
$51.41
|
| Rate for Payer: Monida Montana Health Co-op |
$50.35
|
| Rate for Payer: Monida PacificSource |
$50.35
|
|
|
CD3 (096834)
|
Facility
|
OP
|
$124.00
|
|
|
Service Code
|
HCPCS 86359
|
| Hospital Charge Code |
4063591
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$86.80 |
| Max. Negotiated Rate |
$124.00 |
| Rate for Payer: Aetna Commercial |
$117.80
|
| Rate for Payer: Aetna Medicare |
$111.60
|
| Rate for Payer: BCBS MT CHIP |
$111.60
|
| Rate for Payer: BCBS MT Closed Plan Network |
$117.80
|
| Rate for Payer: BCBS MT HealthLink |
$111.60
|
| Rate for Payer: BCBS MT Medicare |
$111.60
|
| Rate for Payer: BCBS MT POS |
$117.80
|
| Rate for Payer: BCBS MT Traditional |
$124.00
|
| Rate for Payer: Cash Price |
$111.60
|
| Rate for Payer: Cigna Commercial |
$117.80
|
| Rate for Payer: Cigna Medicare |
$111.60
|
| Rate for Payer: Medicaid All Medicaid |
$114.08
|
| Rate for Payer: Medicare All Medicare |
$86.80
|
| Rate for Payer: Monida Allegiance |
$117.80
|
| Rate for Payer: Monida First Choice Health |
$120.28
|
| Rate for Payer: Monida Montana Health Co-op |
$117.80
|
| Rate for Payer: Monida PacificSource |
$117.80
|
|
|
CD3 (096834)
|
Facility
|
IP
|
$124.00
|
|
|
Service Code
|
HCPCS 86359
|
| Hospital Charge Code |
4063591
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$86.80 |
| Max. Negotiated Rate |
$124.00 |
| Rate for Payer: Aetna Commercial |
$117.80
|
| Rate for Payer: Aetna Medicare |
$111.60
|
| Rate for Payer: BCBS MT CHIP |
$111.60
|
| Rate for Payer: BCBS MT Closed Plan Network |
$117.80
|
| Rate for Payer: BCBS MT HealthLink |
$111.60
|
| Rate for Payer: BCBS MT Medicare |
$111.60
|
| Rate for Payer: BCBS MT POS |
$117.80
|
| Rate for Payer: BCBS MT Traditional |
$124.00
|
| Rate for Payer: Cash Price |
$111.60
|
| Rate for Payer: Cigna Commercial |
$117.80
|
| Rate for Payer: Cigna Medicare |
$111.60
|
| Rate for Payer: Medicaid All Medicaid |
$114.08
|
| Rate for Payer: Medicare All Medicare |
$86.80
|
| Rate for Payer: Monida Allegiance |
$117.80
|
| Rate for Payer: Monida First Choice Health |
$120.28
|
| Rate for Payer: Monida Montana Health Co-op |
$117.80
|
| Rate for Payer: Monida PacificSource |
$117.80
|
|
|
CD4 (505008)
|
Facility
|
IP
|
$106.00
|
|
|
Service Code
|
HCPCS 86361
|
| Hospital Charge Code |
4086361
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$74.20 |
| Max. Negotiated Rate |
$106.00 |
| Rate for Payer: Aetna Commercial |
$100.70
|
| Rate for Payer: Aetna Medicare |
$95.40
|
| Rate for Payer: BCBS MT CHIP |
$95.40
|
| Rate for Payer: BCBS MT Closed Plan Network |
$100.70
|
| Rate for Payer: BCBS MT HealthLink |
$95.40
|
| Rate for Payer: BCBS MT Medicare |
$95.40
|
| Rate for Payer: BCBS MT POS |
$100.70
|
| Rate for Payer: BCBS MT Traditional |
$106.00
|
| Rate for Payer: Cash Price |
$95.40
|
| Rate for Payer: Cigna Commercial |
$100.70
|
| Rate for Payer: Cigna Medicare |
$95.40
|
| Rate for Payer: Medicaid All Medicaid |
$97.52
|
| Rate for Payer: Medicare All Medicare |
$74.20
|
| Rate for Payer: Monida Allegiance |
$100.70
|
| Rate for Payer: Monida First Choice Health |
$102.82
|
| Rate for Payer: Monida Montana Health Co-op |
$100.70
|
| Rate for Payer: Monida PacificSource |
$100.70
|
|
|
CD4 (505008)
|
Facility
|
OP
|
$106.00
|
|
|
Service Code
|
HCPCS 86361
|
| Hospital Charge Code |
4086361
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$74.20 |
| Max. Negotiated Rate |
$106.00 |
| Rate for Payer: Aetna Commercial |
$100.70
|
| Rate for Payer: Aetna Medicare |
$95.40
|
| Rate for Payer: BCBS MT CHIP |
$95.40
|
| Rate for Payer: BCBS MT Closed Plan Network |
$100.70
|
| Rate for Payer: BCBS MT HealthLink |
$95.40
|
| Rate for Payer: BCBS MT Medicare |
$95.40
|
| Rate for Payer: BCBS MT POS |
$100.70
|
| Rate for Payer: BCBS MT Traditional |
$106.00
|
| Rate for Payer: Cash Price |
$95.40
|
| Rate for Payer: Cigna Commercial |
$100.70
|
| Rate for Payer: Cigna Medicare |
$95.40
|
| Rate for Payer: Medicaid All Medicaid |
$97.52
|
| Rate for Payer: Medicare All Medicare |
$74.20
|
| Rate for Payer: Monida Allegiance |
$100.70
|
| Rate for Payer: Monida First Choice Health |
$102.82
|
| Rate for Payer: Monida Montana Health Co-op |
$100.70
|
| Rate for Payer: Monida PacificSource |
$100.70
|
|
|
C DIFF AG/TOX EIA
|
Facility
|
OP
|
$39.00
|
|
| Hospital Charge Code |
4087883
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$27.30 |
| Max. Negotiated Rate |
$39.00 |
| Rate for Payer: Aetna Commercial |
$37.05
|
| Rate for Payer: Aetna Medicare |
$35.10
|
| Rate for Payer: BCBS MT CHIP |
$35.10
|
| Rate for Payer: BCBS MT Closed Plan Network |
$37.05
|
| Rate for Payer: BCBS MT HealthLink |
$35.10
|
| Rate for Payer: BCBS MT Medicare |
$35.10
|
| Rate for Payer: BCBS MT POS |
$37.05
|
| Rate for Payer: BCBS MT Traditional |
$39.00
|
| Rate for Payer: Cash Price |
$35.10
|
| Rate for Payer: Cigna Commercial |
$37.05
|
| Rate for Payer: Cigna Medicare |
$35.10
|
| Rate for Payer: Medicaid All Medicaid |
$35.88
|
| Rate for Payer: Medicare All Medicare |
$27.30
|
| Rate for Payer: Monida Allegiance |
$37.05
|
| Rate for Payer: Monida First Choice Health |
$37.83
|
| Rate for Payer: Monida Montana Health Co-op |
$37.05
|
| Rate for Payer: Monida PacificSource |
$37.05
|
|
|
C DIFF AG/TOX EIA
|
Facility
|
IP
|
$39.00
|
|
| Hospital Charge Code |
4087883
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$27.30 |
| Max. Negotiated Rate |
$39.00 |
| Rate for Payer: Aetna Commercial |
$37.05
|
| Rate for Payer: Aetna Medicare |
$35.10
|
| Rate for Payer: BCBS MT CHIP |
$35.10
|
| Rate for Payer: BCBS MT Closed Plan Network |
$37.05
|
| Rate for Payer: BCBS MT HealthLink |
$35.10
|
| Rate for Payer: BCBS MT Medicare |
$35.10
|
| Rate for Payer: BCBS MT POS |
$37.05
|
| Rate for Payer: BCBS MT Traditional |
$39.00
|
| Rate for Payer: Cash Price |
$35.10
|
| Rate for Payer: Cigna Commercial |
$37.05
|
| Rate for Payer: Cigna Medicare |
$35.10
|
| Rate for Payer: Medicaid All Medicaid |
$35.88
|
| Rate for Payer: Medicare All Medicare |
$27.30
|
| Rate for Payer: Monida Allegiance |
$37.05
|
| Rate for Payer: Monida First Choice Health |
$37.83
|
| Rate for Payer: Monida Montana Health Co-op |
$37.05
|
| Rate for Payer: Monida PacificSource |
$37.05
|
|
|
C DIFF TOXIN GENE, NAA (183988)
|
Facility
|
OP
|
$202.00
|
|
|
Service Code
|
HCPCS 87493
|
| Hospital Charge Code |
4087493
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$141.40 |
| Max. Negotiated Rate |
$202.00 |
| Rate for Payer: Aetna Commercial |
$191.90
|
| Rate for Payer: Aetna Medicare |
$181.80
|
| Rate for Payer: BCBS MT CHIP |
$181.80
|
| Rate for Payer: BCBS MT Closed Plan Network |
$191.90
|
| Rate for Payer: BCBS MT HealthLink |
$181.80
|
| Rate for Payer: BCBS MT Medicare |
$181.80
|
| Rate for Payer: BCBS MT POS |
$191.90
|
| Rate for Payer: BCBS MT Traditional |
$202.00
|
| Rate for Payer: Cash Price |
$181.80
|
| Rate for Payer: Cigna Commercial |
$191.90
|
| Rate for Payer: Cigna Medicare |
$181.80
|
| Rate for Payer: Medicaid All Medicaid |
$185.84
|
| Rate for Payer: Medicare All Medicare |
$141.40
|
| Rate for Payer: Monida Allegiance |
$191.90
|
| Rate for Payer: Monida First Choice Health |
$195.94
|
| Rate for Payer: Monida Montana Health Co-op |
$191.90
|
| Rate for Payer: Monida PacificSource |
$191.90
|
|
|
C DIFF TOXIN GENE, NAA (183988)
|
Facility
|
IP
|
$202.00
|
|
|
Service Code
|
HCPCS 87493
|
| Hospital Charge Code |
4087493
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$141.40 |
| Max. Negotiated Rate |
$202.00 |
| Rate for Payer: Aetna Commercial |
$191.90
|
| Rate for Payer: Aetna Medicare |
$181.80
|
| Rate for Payer: BCBS MT CHIP |
$181.80
|
| Rate for Payer: BCBS MT Closed Plan Network |
$191.90
|
| Rate for Payer: BCBS MT HealthLink |
$181.80
|
| Rate for Payer: BCBS MT Medicare |
$181.80
|
| Rate for Payer: BCBS MT POS |
$191.90
|
| Rate for Payer: BCBS MT Traditional |
$202.00
|
| Rate for Payer: Cash Price |
$181.80
|
| Rate for Payer: Cigna Commercial |
$191.90
|
| Rate for Payer: Cigna Medicare |
$181.80
|
| Rate for Payer: Medicaid All Medicaid |
$185.84
|
| Rate for Payer: Medicare All Medicare |
$141.40
|
| Rate for Payer: Monida Allegiance |
$191.90
|
| Rate for Payer: Monida First Choice Health |
$195.94
|
| Rate for Payer: Monida Montana Health Co-op |
$191.90
|
| Rate for Payer: Monida PacificSource |
$191.90
|
|
|
C DIFF TOXINS A & B, EIA (086207)
|
Facility
|
IP
|
$39.00
|
|
|
Service Code
|
HCPCS 87324
|
| Hospital Charge Code |
4087324
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$27.30 |
| Max. Negotiated Rate |
$39.00 |
| Rate for Payer: Aetna Commercial |
$37.05
|
| Rate for Payer: Aetna Medicare |
$35.10
|
| Rate for Payer: BCBS MT CHIP |
$35.10
|
| Rate for Payer: BCBS MT Closed Plan Network |
$37.05
|
| Rate for Payer: BCBS MT HealthLink |
$35.10
|
| Rate for Payer: BCBS MT Medicare |
$35.10
|
| Rate for Payer: BCBS MT POS |
$37.05
|
| Rate for Payer: BCBS MT Traditional |
$39.00
|
| Rate for Payer: Cash Price |
$35.10
|
| Rate for Payer: Cigna Commercial |
$37.05
|
| Rate for Payer: Cigna Medicare |
$35.10
|
| Rate for Payer: Medicaid All Medicaid |
$35.88
|
| Rate for Payer: Medicare All Medicare |
$27.30
|
| Rate for Payer: Monida Allegiance |
$37.05
|
| Rate for Payer: Monida First Choice Health |
$37.83
|
| Rate for Payer: Monida Montana Health Co-op |
$37.05
|
| Rate for Payer: Monida PacificSource |
$37.05
|
|
|
C DIFF TOXINS A & B, EIA (086207)
|
Facility
|
OP
|
$39.00
|
|
|
Service Code
|
HCPCS 87324
|
| Hospital Charge Code |
4087324
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$27.30 |
| Max. Negotiated Rate |
$39.00 |
| Rate for Payer: Aetna Commercial |
$37.05
|
| Rate for Payer: Aetna Medicare |
$35.10
|
| Rate for Payer: BCBS MT CHIP |
$35.10
|
| Rate for Payer: BCBS MT Closed Plan Network |
$37.05
|
| Rate for Payer: BCBS MT HealthLink |
$35.10
|
| Rate for Payer: BCBS MT Medicare |
$35.10
|
| Rate for Payer: BCBS MT POS |
$37.05
|
| Rate for Payer: BCBS MT Traditional |
$39.00
|
| Rate for Payer: Cash Price |
$35.10
|
| Rate for Payer: Cigna Commercial |
$37.05
|
| Rate for Payer: Cigna Medicare |
$35.10
|
| Rate for Payer: Medicaid All Medicaid |
$35.88
|
| Rate for Payer: Medicare All Medicare |
$27.30
|
| Rate for Payer: Monida Allegiance |
$37.05
|
| Rate for Payer: Monida First Choice Health |
$37.83
|
| Rate for Payer: Monida Montana Health Co-op |
$37.05
|
| Rate for Payer: Monida PacificSource |
$37.05
|
|
|
CEFAZOLIN INJ [1GM]
|
Facility
|
IP
|
$26.00
|
|
|
Service Code
|
HCPCS J0690
|
| Hospital Charge Code |
3000073
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$18.20 |
| Max. Negotiated Rate |
$26.00 |
| Rate for Payer: Aetna Commercial |
$24.70
|
| Rate for Payer: Aetna Medicare |
$23.40
|
| Rate for Payer: BCBS MT CHIP |
$23.40
|
| Rate for Payer: BCBS MT Closed Plan Network |
$24.70
|
| Rate for Payer: BCBS MT HealthLink |
$23.40
|
| Rate for Payer: BCBS MT Medicare |
$23.40
|
| Rate for Payer: BCBS MT POS |
$24.70
|
| Rate for Payer: BCBS MT Traditional |
$26.00
|
| Rate for Payer: Cash Price |
$23.40
|
| Rate for Payer: Cigna Commercial |
$24.70
|
| Rate for Payer: Cigna Medicare |
$23.40
|
| Rate for Payer: Medicaid All Medicaid |
$23.92
|
| Rate for Payer: Medicare All Medicare |
$18.20
|
| Rate for Payer: Monida Allegiance |
$24.70
|
| Rate for Payer: Monida First Choice Health |
$25.22
|
| Rate for Payer: Monida Montana Health Co-op |
$24.70
|
| Rate for Payer: Monida PacificSource |
$24.70
|
|
|
CEFAZOLIN INJ [1GM]
|
Facility
|
OP
|
$26.00
|
|
|
Service Code
|
HCPCS J0690
|
| Hospital Charge Code |
3000073
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$18.20 |
| Max. Negotiated Rate |
$26.00 |
| Rate for Payer: Aetna Commercial |
$24.70
|
| Rate for Payer: Aetna Medicare |
$23.40
|
| Rate for Payer: BCBS MT CHIP |
$23.40
|
| Rate for Payer: BCBS MT Closed Plan Network |
$24.70
|
| Rate for Payer: BCBS MT HealthLink |
$23.40
|
| Rate for Payer: BCBS MT Medicare |
$23.40
|
| Rate for Payer: BCBS MT POS |
$24.70
|
| Rate for Payer: BCBS MT Traditional |
$26.00
|
| Rate for Payer: Cash Price |
$23.40
|
| Rate for Payer: Cigna Commercial |
$24.70
|
| Rate for Payer: Cigna Medicare |
$23.40
|
| Rate for Payer: Medicaid All Medicaid |
$23.92
|
| Rate for Payer: Medicare All Medicare |
$18.20
|
| Rate for Payer: Monida Allegiance |
$24.70
|
| Rate for Payer: Monida First Choice Health |
$25.22
|
| Rate for Payer: Monida Montana Health Co-op |
$24.70
|
| Rate for Payer: Monida PacificSource |
$24.70
|
|
|
CEFAZOLIN INJ (2GM)
|
Facility
|
IP
|
$24.00
|
|
|
Service Code
|
NDC 60505623105
|
| Hospital Charge Code |
3007320
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$16.80 |
| Max. Negotiated Rate |
$24.00 |
| Rate for Payer: Aetna Commercial |
$22.80
|
| Rate for Payer: Aetna Medicare |
$21.60
|
| Rate for Payer: BCBS MT CHIP |
$21.60
|
| Rate for Payer: BCBS MT Closed Plan Network |
$22.80
|
| Rate for Payer: BCBS MT HealthLink |
$21.60
|
| Rate for Payer: BCBS MT Medicare |
$21.60
|
| Rate for Payer: BCBS MT POS |
$22.80
|
| Rate for Payer: BCBS MT Traditional |
$24.00
|
| Rate for Payer: Cash Price |
$21.60
|
| Rate for Payer: Cigna Commercial |
$22.80
|
| Rate for Payer: Cigna Medicare |
$21.60
|
| Rate for Payer: Medicaid All Medicaid |
$22.08
|
| Rate for Payer: Medicare All Medicare |
$16.80
|
| Rate for Payer: Monida Allegiance |
$22.80
|
| Rate for Payer: Monida First Choice Health |
$23.28
|
| Rate for Payer: Monida Montana Health Co-op |
$22.80
|
| Rate for Payer: Monida PacificSource |
$22.80
|
|
|
CEFAZOLIN INJ (2GM)
|
Facility
|
OP
|
$24.00
|
|
|
Service Code
|
NDC 60505623105
|
| Hospital Charge Code |
3007320
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$16.80 |
| Max. Negotiated Rate |
$24.00 |
| Rate for Payer: Aetna Commercial |
$22.80
|
| Rate for Payer: Aetna Medicare |
$21.60
|
| Rate for Payer: BCBS MT CHIP |
$21.60
|
| Rate for Payer: BCBS MT Closed Plan Network |
$22.80
|
| Rate for Payer: BCBS MT HealthLink |
$21.60
|
| Rate for Payer: BCBS MT Medicare |
$21.60
|
| Rate for Payer: BCBS MT POS |
$22.80
|
| Rate for Payer: BCBS MT Traditional |
$24.00
|
| Rate for Payer: Cash Price |
$21.60
|
| Rate for Payer: Cigna Commercial |
$22.80
|
| Rate for Payer: Cigna Medicare |
$21.60
|
| Rate for Payer: Medicaid All Medicaid |
$22.08
|
| Rate for Payer: Medicare All Medicare |
$16.80
|
| Rate for Payer: Monida Allegiance |
$22.80
|
| Rate for Payer: Monida First Choice Health |
$23.28
|
| Rate for Payer: Monida Montana Health Co-op |
$22.80
|
| Rate for Payer: Monida PacificSource |
$22.80
|
|
|
CEFDINIR CAP [300 MG] NF
|
Facility
|
IP
|
$13.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
3007481
|
|
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
|
|
|
CEFDINIR CAP [300 MG] NF
|
Facility
|
OP
|
$13.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
3007481
|
|
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
|
|
|
CEFDINIR ORAL SUSP 125MG/5ML
|
Facility
|
OP
|
$164.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
3007232
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$114.80 |
| Max. Negotiated Rate |
$164.00 |
| Rate for Payer: Aetna Commercial |
$155.80
|
| Rate for Payer: Aetna Medicare |
$147.60
|
| Rate for Payer: BCBS MT CHIP |
$147.60
|
| Rate for Payer: BCBS MT Closed Plan Network |
$155.80
|
| Rate for Payer: BCBS MT HealthLink |
$147.60
|
| Rate for Payer: BCBS MT Medicare |
$147.60
|
| Rate for Payer: BCBS MT POS |
$155.80
|
| Rate for Payer: BCBS MT Traditional |
$164.00
|
| Rate for Payer: Cash Price |
$147.60
|
| Rate for Payer: Cigna Commercial |
$155.80
|
| Rate for Payer: Cigna Medicare |
$147.60
|
| Rate for Payer: Medicaid All Medicaid |
$150.88
|
| Rate for Payer: Medicare All Medicare |
$114.80
|
| Rate for Payer: Monida Allegiance |
$155.80
|
| Rate for Payer: Monida First Choice Health |
$159.08
|
| Rate for Payer: Monida Montana Health Co-op |
$155.80
|
| Rate for Payer: Monida PacificSource |
$155.80
|
|
|
CEFDINIR ORAL SUSP 125MG/5ML
|
Facility
|
IP
|
$164.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
3007232
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$114.80 |
| Max. Negotiated Rate |
$164.00 |
| Rate for Payer: Aetna Commercial |
$155.80
|
| Rate for Payer: Aetna Medicare |
$147.60
|
| Rate for Payer: BCBS MT CHIP |
$147.60
|
| Rate for Payer: BCBS MT Closed Plan Network |
$155.80
|
| Rate for Payer: BCBS MT HealthLink |
$147.60
|
| Rate for Payer: BCBS MT Medicare |
$147.60
|
| Rate for Payer: BCBS MT POS |
$155.80
|
| Rate for Payer: BCBS MT Traditional |
$164.00
|
| Rate for Payer: Cash Price |
$147.60
|
| Rate for Payer: Cigna Commercial |
$155.80
|
| Rate for Payer: Cigna Medicare |
$147.60
|
| Rate for Payer: Medicaid All Medicaid |
$150.88
|
| Rate for Payer: Medicare All Medicare |
$114.80
|
| Rate for Payer: Monida Allegiance |
$155.80
|
| Rate for Payer: Monida First Choice Health |
$159.08
|
| Rate for Payer: Monida Montana Health Co-op |
$155.80
|
| Rate for Payer: Monida PacificSource |
$155.80
|
|
|
CEFDINIR ORAL SUSP 250MG/5ML
|
Facility
|
OP
|
$319.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
3007233
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$223.30 |
| Max. Negotiated Rate |
$319.00 |
| Rate for Payer: Aetna Commercial |
$303.05
|
| Rate for Payer: Aetna Medicare |
$287.10
|
| Rate for Payer: BCBS MT CHIP |
$287.10
|
| Rate for Payer: BCBS MT Closed Plan Network |
$303.05
|
| Rate for Payer: BCBS MT HealthLink |
$287.10
|
| Rate for Payer: BCBS MT Medicare |
$287.10
|
| Rate for Payer: BCBS MT POS |
$303.05
|
| Rate for Payer: BCBS MT Traditional |
$319.00
|
| Rate for Payer: Cash Price |
$287.10
|
| Rate for Payer: Cigna Commercial |
$303.05
|
| Rate for Payer: Cigna Medicare |
$287.10
|
| Rate for Payer: Medicaid All Medicaid |
$293.48
|
| Rate for Payer: Medicare All Medicare |
$223.30
|
| Rate for Payer: Monida Allegiance |
$303.05
|
| Rate for Payer: Monida First Choice Health |
$309.43
|
| Rate for Payer: Monida Montana Health Co-op |
$303.05
|
| Rate for Payer: Monida PacificSource |
$303.05
|
|
|
CEFDINIR ORAL SUSP 250MG/5ML
|
Facility
|
IP
|
$319.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
3007233
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$223.30 |
| Max. Negotiated Rate |
$319.00 |
| Rate for Payer: Aetna Commercial |
$303.05
|
| Rate for Payer: Aetna Medicare |
$287.10
|
| Rate for Payer: BCBS MT CHIP |
$287.10
|
| Rate for Payer: BCBS MT Closed Plan Network |
$303.05
|
| Rate for Payer: BCBS MT HealthLink |
$287.10
|
| Rate for Payer: BCBS MT Medicare |
$287.10
|
| Rate for Payer: BCBS MT POS |
$303.05
|
| Rate for Payer: BCBS MT Traditional |
$319.00
|
| Rate for Payer: Cash Price |
$287.10
|
| Rate for Payer: Cigna Commercial |
$303.05
|
| Rate for Payer: Cigna Medicare |
$287.10
|
| Rate for Payer: Medicaid All Medicaid |
$293.48
|
| Rate for Payer: Medicare All Medicare |
$223.30
|
| Rate for Payer: Monida Allegiance |
$303.05
|
| Rate for Payer: Monida First Choice Health |
$309.43
|
| Rate for Payer: Monida Montana Health Co-op |
$303.05
|
| Rate for Payer: Monida PacificSource |
$303.05
|
|
|
CEFEPIME 1GM INJ
|
Facility
|
IP
|
$69.00
|
|
|
Service Code
|
HCPCS J0692
|
| Hospital Charge Code |
3000074
|
|
Hospital Revenue Code
|
636
|
| 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
|
|
|
CEFEPIME 1GM INJ
|
Facility
|
OP
|
$69.00
|
|
|
Service Code
|
HCPCS J0692
|
| Hospital Charge Code |
3000074
|
|
Hospital Revenue Code
|
636
|
| 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
|
|
|
cefTRIAXone 1 GM /NS IVPB : 1GM/100ML
|
Facility
|
OP
|
$26.00
|
|
|
Service Code
|
NDC 99999999999
|
| Hospital Charge Code |
3007011
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$18.20 |
| Max. Negotiated Rate |
$26.00 |
| Rate for Payer: Aetna Commercial |
$24.70
|
| Rate for Payer: Aetna Medicare |
$23.40
|
| Rate for Payer: BCBS MT CHIP |
$23.40
|
| Rate for Payer: BCBS MT Closed Plan Network |
$24.70
|
| Rate for Payer: BCBS MT HealthLink |
$23.40
|
| Rate for Payer: BCBS MT Medicare |
$23.40
|
| Rate for Payer: BCBS MT POS |
$24.70
|
| Rate for Payer: BCBS MT Traditional |
$26.00
|
| Rate for Payer: Cash Price |
$23.40
|
| Rate for Payer: Cigna Commercial |
$24.70
|
| Rate for Payer: Cigna Medicare |
$23.40
|
| Rate for Payer: Medicaid All Medicaid |
$23.92
|
| Rate for Payer: Medicare All Medicare |
$18.20
|
| Rate for Payer: Monida Allegiance |
$24.70
|
| Rate for Payer: Monida First Choice Health |
$25.22
|
| Rate for Payer: Monida Montana Health Co-op |
$24.70
|
| Rate for Payer: Monida PacificSource |
$24.70
|
|
|
cefTRIAXone 1 GM /NS IVPB : 1GM/100ML
|
Facility
|
IP
|
$26.00
|
|
|
Service Code
|
NDC 99999999999
|
| Hospital Charge Code |
3007011
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$18.20 |
| Max. Negotiated Rate |
$26.00 |
| Rate for Payer: Aetna Commercial |
$24.70
|
| Rate for Payer: Aetna Medicare |
$23.40
|
| Rate for Payer: BCBS MT CHIP |
$23.40
|
| Rate for Payer: BCBS MT Closed Plan Network |
$24.70
|
| Rate for Payer: BCBS MT HealthLink |
$23.40
|
| Rate for Payer: BCBS MT Medicare |
$23.40
|
| Rate for Payer: BCBS MT POS |
$24.70
|
| Rate for Payer: BCBS MT Traditional |
$26.00
|
| Rate for Payer: Cash Price |
$23.40
|
| Rate for Payer: Cigna Commercial |
$24.70
|
| Rate for Payer: Cigna Medicare |
$23.40
|
| Rate for Payer: Medicaid All Medicaid |
$23.92
|
| Rate for Payer: Medicare All Medicare |
$18.20
|
| Rate for Payer: Monida Allegiance |
$24.70
|
| Rate for Payer: Monida First Choice Health |
$25.22
|
| Rate for Payer: Monida Montana Health Co-op |
$24.70
|
| Rate for Payer: Monida PacificSource |
$24.70
|
|
