|
CITALOPRAM [20 MG] TAB
|
Facility
|
IP
|
$9.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
3000093
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.30 |
| Max. Negotiated Rate |
$9.00 |
| Rate for Payer: Aetna Commercial |
$8.55
|
| Rate for Payer: Aetna Medicare |
$8.10
|
| Rate for Payer: BCBS MT CHIP |
$8.10
|
| Rate for Payer: BCBS MT Closed Plan Network |
$8.55
|
| Rate for Payer: BCBS MT HealthLink |
$8.10
|
| Rate for Payer: BCBS MT Medicare |
$8.10
|
| Rate for Payer: BCBS MT POS |
$8.55
|
| Rate for Payer: BCBS MT Traditional |
$9.00
|
| Rate for Payer: Cash Price |
$8.10
|
| Rate for Payer: Cigna Commercial |
$8.55
|
| Rate for Payer: Cigna Medicare |
$8.10
|
| Rate for Payer: Medicaid All Medicaid |
$8.28
|
| Rate for Payer: Medicare All Medicare |
$6.30
|
| Rate for Payer: Monida Allegiance |
$8.55
|
| Rate for Payer: Monida First Choice Health |
$8.73
|
| Rate for Payer: Monida Montana Health Co-op |
$8.55
|
| Rate for Payer: Monida PacificSource |
$8.55
|
|
|
CKMB (120816)
|
Facility
|
IP
|
$200.00
|
|
|
Service Code
|
HCPCS 82553
|
| Hospital Charge Code |
4082553
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$140.00 |
| Max. Negotiated Rate |
$200.00 |
| Rate for Payer: Aetna Commercial |
$190.00
|
| Rate for Payer: Aetna Medicare |
$180.00
|
| Rate for Payer: BCBS MT CHIP |
$180.00
|
| Rate for Payer: BCBS MT Closed Plan Network |
$190.00
|
| Rate for Payer: BCBS MT HealthLink |
$180.00
|
| Rate for Payer: BCBS MT Medicare |
$180.00
|
| Rate for Payer: BCBS MT POS |
$190.00
|
| Rate for Payer: BCBS MT Traditional |
$200.00
|
| Rate for Payer: Cash Price |
$180.00
|
| Rate for Payer: Cigna Commercial |
$190.00
|
| Rate for Payer: Cigna Medicare |
$180.00
|
| Rate for Payer: Medicaid All Medicaid |
$184.00
|
| Rate for Payer: Medicare All Medicare |
$140.00
|
| Rate for Payer: Monida Allegiance |
$190.00
|
| Rate for Payer: Monida First Choice Health |
$194.00
|
| Rate for Payer: Monida Montana Health Co-op |
$190.00
|
| Rate for Payer: Monida PacificSource |
$190.00
|
|
|
CKMB (120816)
|
Facility
|
OP
|
$200.00
|
|
|
Service Code
|
HCPCS 82553
|
| Hospital Charge Code |
4082553
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$140.00 |
| Max. Negotiated Rate |
$200.00 |
| Rate for Payer: Aetna Commercial |
$190.00
|
| Rate for Payer: Aetna Medicare |
$180.00
|
| Rate for Payer: BCBS MT CHIP |
$180.00
|
| Rate for Payer: BCBS MT Closed Plan Network |
$190.00
|
| Rate for Payer: BCBS MT HealthLink |
$180.00
|
| Rate for Payer: BCBS MT Medicare |
$180.00
|
| Rate for Payer: BCBS MT POS |
$190.00
|
| Rate for Payer: BCBS MT Traditional |
$200.00
|
| Rate for Payer: Cash Price |
$180.00
|
| Rate for Payer: Cigna Commercial |
$190.00
|
| Rate for Payer: Cigna Medicare |
$180.00
|
| Rate for Payer: Medicaid All Medicaid |
$184.00
|
| Rate for Payer: Medicare All Medicare |
$140.00
|
| Rate for Payer: Monida Allegiance |
$190.00
|
| Rate for Payer: Monida First Choice Health |
$194.00
|
| Rate for Payer: Monida Montana Health Co-op |
$190.00
|
| Rate for Payer: Monida PacificSource |
$190.00
|
|
|
CLARITHROMYCIN 500MG TAB NON FORMULARY
|
Facility
|
OP
|
$20.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
3000094
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$14.00 |
| Max. Negotiated Rate |
$20.00 |
| Rate for Payer: Aetna Commercial |
$19.00
|
| Rate for Payer: Aetna Medicare |
$18.00
|
| Rate for Payer: BCBS MT CHIP |
$18.00
|
| Rate for Payer: BCBS MT Closed Plan Network |
$19.00
|
| Rate for Payer: BCBS MT HealthLink |
$18.00
|
| Rate for Payer: BCBS MT Medicare |
$18.00
|
| Rate for Payer: BCBS MT POS |
$19.00
|
| Rate for Payer: BCBS MT Traditional |
$20.00
|
| Rate for Payer: Cash Price |
$18.00
|
| Rate for Payer: Cigna Commercial |
$19.00
|
| Rate for Payer: Cigna Medicare |
$18.00
|
| Rate for Payer: Medicaid All Medicaid |
$18.40
|
| Rate for Payer: Medicare All Medicare |
$14.00
|
| Rate for Payer: Monida Allegiance |
$19.00
|
| Rate for Payer: Monida First Choice Health |
$19.40
|
| Rate for Payer: Monida Montana Health Co-op |
$19.00
|
| Rate for Payer: Monida PacificSource |
$19.00
|
|
|
CLARITHROMYCIN 500MG TAB NON FORMULARY
|
Facility
|
IP
|
$20.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
3000094
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$14.00 |
| Max. Negotiated Rate |
$20.00 |
| Rate for Payer: Aetna Commercial |
$19.00
|
| Rate for Payer: Aetna Medicare |
$18.00
|
| Rate for Payer: BCBS MT CHIP |
$18.00
|
| Rate for Payer: BCBS MT Closed Plan Network |
$19.00
|
| Rate for Payer: BCBS MT HealthLink |
$18.00
|
| Rate for Payer: BCBS MT Medicare |
$18.00
|
| Rate for Payer: BCBS MT POS |
$19.00
|
| Rate for Payer: BCBS MT Traditional |
$20.00
|
| Rate for Payer: Cash Price |
$18.00
|
| Rate for Payer: Cigna Commercial |
$19.00
|
| Rate for Payer: Cigna Medicare |
$18.00
|
| Rate for Payer: Medicaid All Medicaid |
$18.40
|
| Rate for Payer: Medicare All Medicare |
$14.00
|
| Rate for Payer: Monida Allegiance |
$19.00
|
| Rate for Payer: Monida First Choice Health |
$19.40
|
| Rate for Payer: Monida Montana Health Co-op |
$19.00
|
| Rate for Payer: Monida PacificSource |
$19.00
|
|
|
CLAVICAL SPLINT LG
|
Facility
|
OP
|
$20.00
|
|
| Hospital Charge Code |
2893266
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$14.00 |
| Max. Negotiated Rate |
$20.00 |
| Rate for Payer: Aetna Commercial |
$19.00
|
| Rate for Payer: Aetna Medicare |
$18.00
|
| Rate for Payer: BCBS MT CHIP |
$18.00
|
| Rate for Payer: BCBS MT Closed Plan Network |
$19.00
|
| Rate for Payer: BCBS MT HealthLink |
$18.00
|
| Rate for Payer: BCBS MT Medicare |
$18.00
|
| Rate for Payer: BCBS MT POS |
$19.00
|
| Rate for Payer: BCBS MT Traditional |
$20.00
|
| Rate for Payer: Cash Price |
$18.00
|
| Rate for Payer: Cigna Commercial |
$19.00
|
| Rate for Payer: Cigna Medicare |
$18.00
|
| Rate for Payer: Medicaid All Medicaid |
$18.40
|
| Rate for Payer: Medicare All Medicare |
$14.00
|
| Rate for Payer: Monida Allegiance |
$19.00
|
| Rate for Payer: Monida First Choice Health |
$19.40
|
| Rate for Payer: Monida Montana Health Co-op |
$19.00
|
| Rate for Payer: Monida PacificSource |
$19.00
|
|
|
CLAVICAL SPLINT LG
|
Facility
|
IP
|
$20.00
|
|
| Hospital Charge Code |
2893266
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$14.00 |
| Max. Negotiated Rate |
$20.00 |
| Rate for Payer: Aetna Commercial |
$19.00
|
| Rate for Payer: Aetna Medicare |
$18.00
|
| Rate for Payer: BCBS MT CHIP |
$18.00
|
| Rate for Payer: BCBS MT Closed Plan Network |
$19.00
|
| Rate for Payer: BCBS MT HealthLink |
$18.00
|
| Rate for Payer: BCBS MT Medicare |
$18.00
|
| Rate for Payer: BCBS MT POS |
$19.00
|
| Rate for Payer: BCBS MT Traditional |
$20.00
|
| Rate for Payer: Cash Price |
$18.00
|
| Rate for Payer: Cigna Commercial |
$19.00
|
| Rate for Payer: Cigna Medicare |
$18.00
|
| Rate for Payer: Medicaid All Medicaid |
$18.40
|
| Rate for Payer: Medicare All Medicare |
$14.00
|
| Rate for Payer: Monida Allegiance |
$19.00
|
| Rate for Payer: Monida First Choice Health |
$19.40
|
| Rate for Payer: Monida Montana Health Co-op |
$19.00
|
| Rate for Payer: Monida PacificSource |
$19.00
|
|
|
CLAVICAL SPLINT MD
|
Facility
|
OP
|
$20.00
|
|
| Hospital Charge Code |
2893265
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$14.00 |
| Max. Negotiated Rate |
$20.00 |
| Rate for Payer: Aetna Commercial |
$19.00
|
| Rate for Payer: Aetna Medicare |
$18.00
|
| Rate for Payer: BCBS MT CHIP |
$18.00
|
| Rate for Payer: BCBS MT Closed Plan Network |
$19.00
|
| Rate for Payer: BCBS MT HealthLink |
$18.00
|
| Rate for Payer: BCBS MT Medicare |
$18.00
|
| Rate for Payer: BCBS MT POS |
$19.00
|
| Rate for Payer: BCBS MT Traditional |
$20.00
|
| Rate for Payer: Cash Price |
$18.00
|
| Rate for Payer: Cigna Commercial |
$19.00
|
| Rate for Payer: Cigna Medicare |
$18.00
|
| Rate for Payer: Medicaid All Medicaid |
$18.40
|
| Rate for Payer: Medicare All Medicare |
$14.00
|
| Rate for Payer: Monida Allegiance |
$19.00
|
| Rate for Payer: Monida First Choice Health |
$19.40
|
| Rate for Payer: Monida Montana Health Co-op |
$19.00
|
| Rate for Payer: Monida PacificSource |
$19.00
|
|
|
CLAVICAL SPLINT MD
|
Facility
|
IP
|
$20.00
|
|
| Hospital Charge Code |
2893265
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$14.00 |
| Max. Negotiated Rate |
$20.00 |
| Rate for Payer: Aetna Commercial |
$19.00
|
| Rate for Payer: Aetna Medicare |
$18.00
|
| Rate for Payer: BCBS MT CHIP |
$18.00
|
| Rate for Payer: BCBS MT Closed Plan Network |
$19.00
|
| Rate for Payer: BCBS MT HealthLink |
$18.00
|
| Rate for Payer: BCBS MT Medicare |
$18.00
|
| Rate for Payer: BCBS MT POS |
$19.00
|
| Rate for Payer: BCBS MT Traditional |
$20.00
|
| Rate for Payer: Cash Price |
$18.00
|
| Rate for Payer: Cigna Commercial |
$19.00
|
| Rate for Payer: Cigna Medicare |
$18.00
|
| Rate for Payer: Medicaid All Medicaid |
$18.40
|
| Rate for Payer: Medicare All Medicare |
$14.00
|
| Rate for Payer: Monida Allegiance |
$19.00
|
| Rate for Payer: Monida First Choice Health |
$19.40
|
| Rate for Payer: Monida Montana Health Co-op |
$19.00
|
| Rate for Payer: Monida PacificSource |
$19.00
|
|
|
CLAVICAL SPLINT SM
|
Facility
|
OP
|
$20.00
|
|
| Hospital Charge Code |
2893264
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$14.00 |
| Max. Negotiated Rate |
$20.00 |
| Rate for Payer: Aetna Commercial |
$19.00
|
| Rate for Payer: Aetna Medicare |
$18.00
|
| Rate for Payer: BCBS MT CHIP |
$18.00
|
| Rate for Payer: BCBS MT Closed Plan Network |
$19.00
|
| Rate for Payer: BCBS MT HealthLink |
$18.00
|
| Rate for Payer: BCBS MT Medicare |
$18.00
|
| Rate for Payer: BCBS MT POS |
$19.00
|
| Rate for Payer: BCBS MT Traditional |
$20.00
|
| Rate for Payer: Cash Price |
$18.00
|
| Rate for Payer: Cigna Commercial |
$19.00
|
| Rate for Payer: Cigna Medicare |
$18.00
|
| Rate for Payer: Medicaid All Medicaid |
$18.40
|
| Rate for Payer: Medicare All Medicare |
$14.00
|
| Rate for Payer: Monida Allegiance |
$19.00
|
| Rate for Payer: Monida First Choice Health |
$19.40
|
| Rate for Payer: Monida Montana Health Co-op |
$19.00
|
| Rate for Payer: Monida PacificSource |
$19.00
|
|
|
CLAVICAL SPLINT SM
|
Facility
|
IP
|
$20.00
|
|
| Hospital Charge Code |
2893264
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$14.00 |
| Max. Negotiated Rate |
$20.00 |
| Rate for Payer: Aetna Commercial |
$19.00
|
| Rate for Payer: Aetna Medicare |
$18.00
|
| Rate for Payer: BCBS MT CHIP |
$18.00
|
| Rate for Payer: BCBS MT Closed Plan Network |
$19.00
|
| Rate for Payer: BCBS MT HealthLink |
$18.00
|
| Rate for Payer: BCBS MT Medicare |
$18.00
|
| Rate for Payer: BCBS MT POS |
$19.00
|
| Rate for Payer: BCBS MT Traditional |
$20.00
|
| Rate for Payer: Cash Price |
$18.00
|
| Rate for Payer: Cigna Commercial |
$19.00
|
| Rate for Payer: Cigna Medicare |
$18.00
|
| Rate for Payer: Medicaid All Medicaid |
$18.40
|
| Rate for Payer: Medicare All Medicare |
$14.00
|
| Rate for Payer: Monida Allegiance |
$19.00
|
| Rate for Payer: Monida First Choice Health |
$19.40
|
| Rate for Payer: Monida Montana Health Co-op |
$19.00
|
| Rate for Payer: Monida PacificSource |
$19.00
|
|
|
CLAVICAL SPLINT XL
|
Facility
|
OP
|
$20.00
|
|
| Hospital Charge Code |
2893267
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$14.00 |
| Max. Negotiated Rate |
$20.00 |
| Rate for Payer: Aetna Commercial |
$19.00
|
| Rate for Payer: Aetna Medicare |
$18.00
|
| Rate for Payer: BCBS MT CHIP |
$18.00
|
| Rate for Payer: BCBS MT Closed Plan Network |
$19.00
|
| Rate for Payer: BCBS MT HealthLink |
$18.00
|
| Rate for Payer: BCBS MT Medicare |
$18.00
|
| Rate for Payer: BCBS MT POS |
$19.00
|
| Rate for Payer: BCBS MT Traditional |
$20.00
|
| Rate for Payer: Cash Price |
$18.00
|
| Rate for Payer: Cigna Commercial |
$19.00
|
| Rate for Payer: Cigna Medicare |
$18.00
|
| Rate for Payer: Medicaid All Medicaid |
$18.40
|
| Rate for Payer: Medicare All Medicare |
$14.00
|
| Rate for Payer: Monida Allegiance |
$19.00
|
| Rate for Payer: Monida First Choice Health |
$19.40
|
| Rate for Payer: Monida Montana Health Co-op |
$19.00
|
| Rate for Payer: Monida PacificSource |
$19.00
|
|
|
CLAVICAL SPLINT XL
|
Facility
|
IP
|
$20.00
|
|
| Hospital Charge Code |
2893267
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$14.00 |
| Max. Negotiated Rate |
$20.00 |
| Rate for Payer: Aetna Commercial |
$19.00
|
| Rate for Payer: Aetna Medicare |
$18.00
|
| Rate for Payer: BCBS MT CHIP |
$18.00
|
| Rate for Payer: BCBS MT Closed Plan Network |
$19.00
|
| Rate for Payer: BCBS MT HealthLink |
$18.00
|
| Rate for Payer: BCBS MT Medicare |
$18.00
|
| Rate for Payer: BCBS MT POS |
$19.00
|
| Rate for Payer: BCBS MT Traditional |
$20.00
|
| Rate for Payer: Cash Price |
$18.00
|
| Rate for Payer: Cigna Commercial |
$19.00
|
| Rate for Payer: Cigna Medicare |
$18.00
|
| Rate for Payer: Medicaid All Medicaid |
$18.40
|
| Rate for Payer: Medicare All Medicare |
$14.00
|
| Rate for Payer: Monida Allegiance |
$19.00
|
| Rate for Payer: Monida First Choice Health |
$19.40
|
| Rate for Payer: Monida Montana Health Co-op |
$19.00
|
| Rate for Payer: Monida PacificSource |
$19.00
|
|
|
CLAVICL SPLINT UNIVERSAL
|
Facility
|
OP
|
$38.00
|
|
| Hospital Charge Code |
2893268
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$26.60 |
| Max. Negotiated Rate |
$38.00 |
| Rate for Payer: Aetna Commercial |
$36.10
|
| Rate for Payer: Aetna Medicare |
$34.20
|
| Rate for Payer: BCBS MT CHIP |
$34.20
|
| Rate for Payer: BCBS MT Closed Plan Network |
$36.10
|
| Rate for Payer: BCBS MT HealthLink |
$34.20
|
| Rate for Payer: BCBS MT Medicare |
$34.20
|
| Rate for Payer: BCBS MT POS |
$36.10
|
| Rate for Payer: BCBS MT Traditional |
$38.00
|
| Rate for Payer: Cash Price |
$34.20
|
| Rate for Payer: Cigna Commercial |
$36.10
|
| Rate for Payer: Cigna Medicare |
$34.20
|
| Rate for Payer: Medicaid All Medicaid |
$34.96
|
| Rate for Payer: Medicare All Medicare |
$26.60
|
| Rate for Payer: Monida Allegiance |
$36.10
|
| Rate for Payer: Monida First Choice Health |
$36.86
|
| Rate for Payer: Monida Montana Health Co-op |
$36.10
|
| Rate for Payer: Monida PacificSource |
$36.10
|
|
|
CLAVICL SPLINT UNIVERSAL
|
Facility
|
IP
|
$38.00
|
|
| Hospital Charge Code |
2893268
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$26.60 |
| Max. Negotiated Rate |
$38.00 |
| Rate for Payer: Aetna Commercial |
$36.10
|
| Rate for Payer: Aetna Medicare |
$34.20
|
| Rate for Payer: BCBS MT CHIP |
$34.20
|
| Rate for Payer: BCBS MT Closed Plan Network |
$36.10
|
| Rate for Payer: BCBS MT HealthLink |
$34.20
|
| Rate for Payer: BCBS MT Medicare |
$34.20
|
| Rate for Payer: BCBS MT POS |
$36.10
|
| Rate for Payer: BCBS MT Traditional |
$38.00
|
| Rate for Payer: Cash Price |
$34.20
|
| Rate for Payer: Cigna Commercial |
$36.10
|
| Rate for Payer: Cigna Medicare |
$34.20
|
| Rate for Payer: Medicaid All Medicaid |
$34.96
|
| Rate for Payer: Medicare All Medicare |
$26.60
|
| Rate for Payer: Monida Allegiance |
$36.10
|
| Rate for Payer: Monida First Choice Health |
$36.86
|
| Rate for Payer: Monida Montana Health Co-op |
$36.10
|
| Rate for Payer: Monida PacificSource |
$36.10
|
|
|
CLEANSING FOAM
|
Facility
|
IP
|
$25.00
|
|
| Hospital Charge Code |
2830251
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$17.50 |
| Max. Negotiated Rate |
$25.00 |
| Rate for Payer: Aetna Commercial |
$23.75
|
| Rate for Payer: Aetna Medicare |
$22.50
|
| Rate for Payer: BCBS MT CHIP |
$22.50
|
| Rate for Payer: BCBS MT Closed Plan Network |
$23.75
|
| Rate for Payer: BCBS MT HealthLink |
$22.50
|
| Rate for Payer: BCBS MT Medicare |
$22.50
|
| Rate for Payer: BCBS MT POS |
$23.75
|
| Rate for Payer: BCBS MT Traditional |
$25.00
|
| Rate for Payer: Cash Price |
$22.50
|
| Rate for Payer: Cigna Commercial |
$23.75
|
| Rate for Payer: Cigna Medicare |
$22.50
|
| Rate for Payer: Medicaid All Medicaid |
$23.00
|
| Rate for Payer: Medicare All Medicare |
$17.50
|
| Rate for Payer: Monida Allegiance |
$23.75
|
| Rate for Payer: Monida First Choice Health |
$24.25
|
| Rate for Payer: Monida Montana Health Co-op |
$23.75
|
| Rate for Payer: Monida PacificSource |
$23.75
|
|
|
CLEANSING FOAM
|
Facility
|
OP
|
$25.00
|
|
| Hospital Charge Code |
2830251
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$17.50 |
| Max. Negotiated Rate |
$25.00 |
| Rate for Payer: Aetna Commercial |
$23.75
|
| Rate for Payer: Aetna Medicare |
$22.50
|
| Rate for Payer: BCBS MT CHIP |
$22.50
|
| Rate for Payer: BCBS MT Closed Plan Network |
$23.75
|
| Rate for Payer: BCBS MT HealthLink |
$22.50
|
| Rate for Payer: BCBS MT Medicare |
$22.50
|
| Rate for Payer: BCBS MT POS |
$23.75
|
| Rate for Payer: BCBS MT Traditional |
$25.00
|
| Rate for Payer: Cash Price |
$22.50
|
| Rate for Payer: Cigna Commercial |
$23.75
|
| Rate for Payer: Cigna Medicare |
$22.50
|
| Rate for Payer: Medicaid All Medicaid |
$23.00
|
| Rate for Payer: Medicare All Medicare |
$17.50
|
| Rate for Payer: Monida Allegiance |
$23.75
|
| Rate for Payer: Monida First Choice Health |
$24.25
|
| Rate for Payer: Monida Montana Health Co-op |
$23.75
|
| Rate for Payer: Monida PacificSource |
$23.75
|
|
|
CLINDAMYCIN CAP [150 MG]
|
Facility
|
IP
|
$8.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
3000095
|
|
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
|
|
|
CLINDAMYCIN CAP [150 MG]
|
Facility
|
OP
|
$8.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
3000095
|
|
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
|
|
|
CLINDAMYCIN INJ [600 MG/4 ML] IM
|
Facility
|
OP
|
$25.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
3000096
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$17.50 |
| Max. Negotiated Rate |
$25.00 |
| Rate for Payer: Aetna Commercial |
$23.75
|
| Rate for Payer: Aetna Medicare |
$22.50
|
| Rate for Payer: BCBS MT CHIP |
$22.50
|
| Rate for Payer: BCBS MT Closed Plan Network |
$23.75
|
| Rate for Payer: BCBS MT HealthLink |
$22.50
|
| Rate for Payer: BCBS MT Medicare |
$22.50
|
| Rate for Payer: BCBS MT POS |
$23.75
|
| Rate for Payer: BCBS MT Traditional |
$25.00
|
| Rate for Payer: Cash Price |
$22.50
|
| Rate for Payer: Cigna Commercial |
$23.75
|
| Rate for Payer: Cigna Medicare |
$22.50
|
| Rate for Payer: Medicaid All Medicaid |
$23.00
|
| Rate for Payer: Medicare All Medicare |
$17.50
|
| Rate for Payer: Monida Allegiance |
$23.75
|
| Rate for Payer: Monida First Choice Health |
$24.25
|
| Rate for Payer: Monida Montana Health Co-op |
$23.75
|
| Rate for Payer: Monida PacificSource |
$23.75
|
|
|
CLINDAMYCIN INJ [600 MG/4 ML] IM
|
Facility
|
IP
|
$25.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
3000096
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$17.50 |
| Max. Negotiated Rate |
$25.00 |
| Rate for Payer: Aetna Commercial |
$23.75
|
| Rate for Payer: Aetna Medicare |
$22.50
|
| Rate for Payer: BCBS MT CHIP |
$22.50
|
| Rate for Payer: BCBS MT Closed Plan Network |
$23.75
|
| Rate for Payer: BCBS MT HealthLink |
$22.50
|
| Rate for Payer: BCBS MT Medicare |
$22.50
|
| Rate for Payer: BCBS MT POS |
$23.75
|
| Rate for Payer: BCBS MT Traditional |
$25.00
|
| Rate for Payer: Cash Price |
$22.50
|
| Rate for Payer: Cigna Commercial |
$23.75
|
| Rate for Payer: Cigna Medicare |
$22.50
|
| Rate for Payer: Medicaid All Medicaid |
$23.00
|
| Rate for Payer: Medicare All Medicare |
$17.50
|
| Rate for Payer: Monida Allegiance |
$23.75
|
| Rate for Payer: Monida First Choice Health |
$24.25
|
| Rate for Payer: Monida Montana Health Co-op |
$23.75
|
| Rate for Payer: Monida PacificSource |
$23.75
|
|
|
CLIN DEXAMETHASONE ELIXIR 0.5MG / 5ML
|
Facility
|
OP
|
$5.00
|
|
|
Service Code
|
NDC 64980050924
|
| Hospital Charge Code |
3007106
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.50 |
| Max. Negotiated Rate |
$5.00 |
| Rate for Payer: Aetna Commercial |
$4.75
|
| Rate for Payer: Aetna Medicare |
$4.50
|
| Rate for Payer: BCBS MT CHIP |
$4.50
|
| Rate for Payer: BCBS MT Closed Plan Network |
$4.75
|
| Rate for Payer: BCBS MT HealthLink |
$4.50
|
| Rate for Payer: BCBS MT Medicare |
$4.50
|
| Rate for Payer: BCBS MT POS |
$4.75
|
| Rate for Payer: BCBS MT Traditional |
$5.00
|
| Rate for Payer: Cash Price |
$4.50
|
| Rate for Payer: Cigna Commercial |
$4.75
|
| Rate for Payer: Cigna Medicare |
$4.50
|
| Rate for Payer: Medicaid All Medicaid |
$4.60
|
| Rate for Payer: Medicare All Medicare |
$3.50
|
| Rate for Payer: Monida Allegiance |
$4.75
|
| Rate for Payer: Monida First Choice Health |
$4.85
|
| Rate for Payer: Monida Montana Health Co-op |
$4.75
|
| Rate for Payer: Monida PacificSource |
$4.75
|
|
|
CLIN DEXAMETHASONE ELIXIR 0.5MG / 5ML
|
Facility
|
IP
|
$5.00
|
|
|
Service Code
|
NDC 64980050924
|
| Hospital Charge Code |
3007106
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.50 |
| Max. Negotiated Rate |
$5.00 |
| Rate for Payer: Aetna Commercial |
$4.75
|
| Rate for Payer: Aetna Medicare |
$4.50
|
| Rate for Payer: BCBS MT CHIP |
$4.50
|
| Rate for Payer: BCBS MT Closed Plan Network |
$4.75
|
| Rate for Payer: BCBS MT HealthLink |
$4.50
|
| Rate for Payer: BCBS MT Medicare |
$4.50
|
| Rate for Payer: BCBS MT POS |
$4.75
|
| Rate for Payer: BCBS MT Traditional |
$5.00
|
| Rate for Payer: Cash Price |
$4.50
|
| Rate for Payer: Cigna Commercial |
$4.75
|
| Rate for Payer: Cigna Medicare |
$4.50
|
| Rate for Payer: Medicaid All Medicaid |
$4.60
|
| Rate for Payer: Medicare All Medicare |
$3.50
|
| Rate for Payer: Monida Allegiance |
$4.75
|
| Rate for Payer: Monida First Choice Health |
$4.85
|
| Rate for Payer: Monida Montana Health Co-op |
$4.75
|
| Rate for Payer: Monida PacificSource |
$4.75
|
|
|
CLIN DIPHENHYDRAMINE LIQUID 12.5MG / 5ML
|
Facility
|
IP
|
$7.00
|
|
|
Service Code
|
NDC 51432056818
|
| Hospital Charge Code |
3007105
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.90 |
| Max. Negotiated Rate |
$7.00 |
| Rate for Payer: Aetna Commercial |
$6.65
|
| Rate for Payer: Aetna Medicare |
$6.30
|
| Rate for Payer: BCBS MT CHIP |
$6.30
|
| Rate for Payer: BCBS MT Closed Plan Network |
$6.65
|
| Rate for Payer: BCBS MT HealthLink |
$6.30
|
| Rate for Payer: BCBS MT Medicare |
$6.30
|
| Rate for Payer: BCBS MT POS |
$6.65
|
| Rate for Payer: BCBS MT Traditional |
$7.00
|
| Rate for Payer: Cash Price |
$6.30
|
| Rate for Payer: Cigna Commercial |
$6.65
|
| Rate for Payer: Cigna Medicare |
$6.30
|
| Rate for Payer: Medicaid All Medicaid |
$6.44
|
| Rate for Payer: Medicare All Medicare |
$4.90
|
| Rate for Payer: Monida Allegiance |
$6.65
|
| Rate for Payer: Monida First Choice Health |
$6.79
|
| Rate for Payer: Monida Montana Health Co-op |
$6.65
|
| Rate for Payer: Monida PacificSource |
$6.65
|
|
|
CLIN DIPHENHYDRAMINE LIQUID 12.5MG / 5ML
|
Facility
|
OP
|
$7.00
|
|
|
Service Code
|
NDC 51432056818
|
| Hospital Charge Code |
3007105
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.90 |
| Max. Negotiated Rate |
$7.00 |
| Rate for Payer: Aetna Commercial |
$6.65
|
| Rate for Payer: Aetna Medicare |
$6.30
|
| Rate for Payer: BCBS MT CHIP |
$6.30
|
| Rate for Payer: BCBS MT Closed Plan Network |
$6.65
|
| Rate for Payer: BCBS MT HealthLink |
$6.30
|
| Rate for Payer: BCBS MT Medicare |
$6.30
|
| Rate for Payer: BCBS MT POS |
$6.65
|
| Rate for Payer: BCBS MT Traditional |
$7.00
|
| Rate for Payer: Cash Price |
$6.30
|
| Rate for Payer: Cigna Commercial |
$6.65
|
| Rate for Payer: Cigna Medicare |
$6.30
|
| Rate for Payer: Medicaid All Medicaid |
$6.44
|
| Rate for Payer: Medicare All Medicare |
$4.90
|
| Rate for Payer: Monida Allegiance |
$6.65
|
| Rate for Payer: Monida First Choice Health |
$6.79
|
| Rate for Payer: Monida Montana Health Co-op |
$6.65
|
| Rate for Payer: Monida PacificSource |
$6.65
|
|
