|
CEFAZOLIN INJ (2GM)
|
Facility
|
OP
|
$24.00
|
|
|
Service Code
|
HCPCS J0690
|
| 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
|
OP
|
$13.00
|
|
|
Service Code
|
HCPCS J8499
|
| 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
|
IP
|
$13.00
|
|
|
Service Code
|
HCPCS J8499
|
| 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 J8499
|
| 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 J8499
|
| 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 J8499
|
| 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 J8499
|
| 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 [1 GM] 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 [1 GM] 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
|
|
|
CEFEPIME [2 GM] INJ
|
Facility
|
IP
|
$130.00
|
|
|
Service Code
|
HCPCS J0692
|
| Hospital Charge Code |
3007647
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$91.00 |
| Max. Negotiated Rate |
$130.00 |
| Rate for Payer: Aetna Commercial |
$123.50
|
| Rate for Payer: Aetna Medicare |
$117.00
|
| Rate for Payer: BCBS MT CHIP |
$117.00
|
| Rate for Payer: BCBS MT Closed Plan Network |
$123.50
|
| Rate for Payer: BCBS MT HealthLink |
$117.00
|
| Rate for Payer: BCBS MT Medicare |
$117.00
|
| Rate for Payer: BCBS MT POS |
$123.50
|
| Rate for Payer: BCBS MT Traditional |
$130.00
|
| Rate for Payer: Cash Price |
$117.00
|
| Rate for Payer: Cigna Commercial |
$123.50
|
| Rate for Payer: Cigna Medicare |
$117.00
|
| Rate for Payer: Medicaid All Medicaid |
$119.60
|
| Rate for Payer: Medicare All Medicare |
$91.00
|
| Rate for Payer: Monida Allegiance |
$123.50
|
| Rate for Payer: Monida First Choice Health |
$126.10
|
| Rate for Payer: Monida Montana Health Co-op |
$123.50
|
| Rate for Payer: Monida PacificSource |
$123.50
|
|
|
CEFEPIME [2 GM] INJ
|
Facility
|
OP
|
$130.00
|
|
|
Service Code
|
HCPCS J0692
|
| Hospital Charge Code |
3007647
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$91.00 |
| Max. Negotiated Rate |
$130.00 |
| Rate for Payer: Aetna Commercial |
$123.50
|
| Rate for Payer: Aetna Medicare |
$117.00
|
| Rate for Payer: BCBS MT CHIP |
$117.00
|
| Rate for Payer: BCBS MT Closed Plan Network |
$123.50
|
| Rate for Payer: BCBS MT HealthLink |
$117.00
|
| Rate for Payer: BCBS MT Medicare |
$117.00
|
| Rate for Payer: BCBS MT POS |
$123.50
|
| Rate for Payer: BCBS MT Traditional |
$130.00
|
| Rate for Payer: Cash Price |
$117.00
|
| Rate for Payer: Cigna Commercial |
$123.50
|
| Rate for Payer: Cigna Medicare |
$117.00
|
| Rate for Payer: Medicaid All Medicaid |
$119.60
|
| Rate for Payer: Medicare All Medicare |
$91.00
|
| Rate for Payer: Monida Allegiance |
$123.50
|
| Rate for Payer: Monida First Choice Health |
$126.10
|
| Rate for Payer: Monida Montana Health Co-op |
$123.50
|
| Rate for Payer: Monida PacificSource |
$123.50
|
|
|
cefTRIAXone 2 GM /NS IVPB : 2GM/100mL
|
Facility
|
IP
|
$26.00
|
|
| Hospital Charge Code |
3007012
|
|
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 2 GM /NS IVPB : 2GM/100mL
|
Facility
|
OP
|
$26.00
|
|
| Hospital Charge Code |
3007012
|
|
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 (ROCEPHIN) 1GM INJ
|
Facility
|
IP
|
$26.00
|
|
|
Service Code
|
HCPCS J0696
|
| Hospital Charge Code |
3000075
|
|
Hospital Revenue Code
|
250
|
| 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 (ROCEPHIN) 1GM INJ
|
Facility
|
OP
|
$26.00
|
|
|
Service Code
|
HCPCS J0696
|
| Hospital Charge Code |
3000075
|
|
Hospital Revenue Code
|
250
|
| 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 (ROCEPHIN) 2GM INJ
|
Facility
|
IP
|
$26.00
|
|
|
Service Code
|
HCPCS J0696
|
| Hospital Charge Code |
3007137
|
|
Hospital Revenue Code
|
250
|
| 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 (ROCEPHIN) 2GM INJ
|
Facility
|
OP
|
$26.00
|
|
|
Service Code
|
HCPCS J0696
|
| Hospital Charge Code |
3007137
|
|
Hospital Revenue Code
|
250
|
| 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
|
|
|
cefUROXime TAB [250 MG]
|
Facility
|
OP
|
$13.00
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
3000076
|
|
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
|
|
|
cefUROXime TAB [250 MG]
|
Facility
|
IP
|
$13.00
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
3000076
|
|
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
|
|
|
CELECOXIB CAP [100 MG]
|
Facility
|
OP
|
$15.00
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
3000077
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.50 |
| Max. Negotiated Rate |
$15.00 |
| Rate for Payer: Aetna Commercial |
$14.25
|
| Rate for Payer: Aetna Medicare |
$13.50
|
| Rate for Payer: BCBS MT CHIP |
$13.50
|
| Rate for Payer: BCBS MT Closed Plan Network |
$14.25
|
| Rate for Payer: BCBS MT HealthLink |
$13.50
|
| Rate for Payer: BCBS MT Medicare |
$13.50
|
| Rate for Payer: BCBS MT POS |
$14.25
|
| Rate for Payer: BCBS MT Traditional |
$15.00
|
| Rate for Payer: Cash Price |
$13.50
|
| Rate for Payer: Cigna Commercial |
$14.25
|
| Rate for Payer: Cigna Medicare |
$13.50
|
| Rate for Payer: Medicaid All Medicaid |
$13.80
|
| Rate for Payer: Medicare All Medicare |
$10.50
|
| Rate for Payer: Monida Allegiance |
$14.25
|
| Rate for Payer: Monida First Choice Health |
$14.55
|
| Rate for Payer: Monida Montana Health Co-op |
$14.25
|
| Rate for Payer: Monida PacificSource |
$14.25
|
|
|
CELECOXIB CAP [100 MG]
|
Facility
|
IP
|
$15.00
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
3000077
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.50 |
| Max. Negotiated Rate |
$15.00 |
| Rate for Payer: Aetna Commercial |
$14.25
|
| Rate for Payer: Aetna Medicare |
$13.50
|
| Rate for Payer: BCBS MT CHIP |
$13.50
|
| Rate for Payer: BCBS MT Closed Plan Network |
$14.25
|
| Rate for Payer: BCBS MT HealthLink |
$13.50
|
| Rate for Payer: BCBS MT Medicare |
$13.50
|
| Rate for Payer: BCBS MT POS |
$14.25
|
| Rate for Payer: BCBS MT Traditional |
$15.00
|
| Rate for Payer: Cash Price |
$13.50
|
| Rate for Payer: Cigna Commercial |
$14.25
|
| Rate for Payer: Cigna Medicare |
$13.50
|
| Rate for Payer: Medicaid All Medicaid |
$13.80
|
| Rate for Payer: Medicare All Medicare |
$10.50
|
| Rate for Payer: Monida Allegiance |
$14.25
|
| Rate for Payer: Monida First Choice Health |
$14.55
|
| Rate for Payer: Monida Montana Health Co-op |
$14.25
|
| Rate for Payer: Monida PacificSource |
$14.25
|
|
|
CELIAC DISEASE CASCADE
|
Facility
|
OP
|
$172.00
|
|
|
Service Code
|
CPT 86364
|
| Hospital Charge Code |
4088053
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$120.40 |
| Max. Negotiated Rate |
$172.00 |
| Rate for Payer: Aetna Commercial |
$163.40
|
| Rate for Payer: Aetna Medicare |
$154.80
|
| Rate for Payer: BCBS MT CHIP |
$154.80
|
| Rate for Payer: BCBS MT Closed Plan Network |
$163.40
|
| Rate for Payer: BCBS MT HealthLink |
$154.80
|
| Rate for Payer: BCBS MT Medicare |
$154.80
|
| Rate for Payer: BCBS MT POS |
$163.40
|
| Rate for Payer: BCBS MT Traditional |
$172.00
|
| Rate for Payer: Cash Price |
$154.80
|
| Rate for Payer: Cigna Commercial |
$163.40
|
| Rate for Payer: Cigna Medicare |
$154.80
|
| Rate for Payer: Medicaid All Medicaid |
$158.24
|
| Rate for Payer: Medicare All Medicare |
$120.40
|
| Rate for Payer: Monida Allegiance |
$163.40
|
| Rate for Payer: Monida First Choice Health |
$166.84
|
| Rate for Payer: Monida Montana Health Co-op |
$163.40
|
| Rate for Payer: Monida PacificSource |
$163.40
|
|
|
CELIAC DISEASE CASCADE
|
Facility
|
IP
|
$172.00
|
|
|
Service Code
|
CPT 86364
|
| Hospital Charge Code |
4088053
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$120.40 |
| Max. Negotiated Rate |
$172.00 |
| Rate for Payer: Aetna Commercial |
$163.40
|
| Rate for Payer: Aetna Medicare |
$154.80
|
| Rate for Payer: BCBS MT CHIP |
$154.80
|
| Rate for Payer: BCBS MT Closed Plan Network |
$163.40
|
| Rate for Payer: BCBS MT HealthLink |
$154.80
|
| Rate for Payer: BCBS MT Medicare |
$154.80
|
| Rate for Payer: BCBS MT POS |
$163.40
|
| Rate for Payer: BCBS MT Traditional |
$172.00
|
| Rate for Payer: Cash Price |
$154.80
|
| Rate for Payer: Cigna Commercial |
$163.40
|
| Rate for Payer: Cigna Medicare |
$154.80
|
| Rate for Payer: Medicaid All Medicaid |
$158.24
|
| Rate for Payer: Medicare All Medicare |
$120.40
|
| Rate for Payer: Monida Allegiance |
$163.40
|
| Rate for Payer: Monida First Choice Health |
$166.84
|
| Rate for Payer: Monida Montana Health Co-op |
$163.40
|
| Rate for Payer: Monida PacificSource |
$163.40
|
|
|
CELIAC DSE COMPREHENSIVE CASCADE
|
Facility
|
OP
|
$263.00
|
|
|
Service Code
|
CPT 81376
|
| Hospital Charge Code |
4088007
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$184.10 |
| Max. Negotiated Rate |
$263.00 |
| Rate for Payer: Aetna Commercial |
$249.85
|
| Rate for Payer: Aetna Medicare |
$236.70
|
| Rate for Payer: BCBS MT CHIP |
$236.70
|
| Rate for Payer: BCBS MT Closed Plan Network |
$249.85
|
| Rate for Payer: BCBS MT HealthLink |
$236.70
|
| Rate for Payer: BCBS MT Medicare |
$236.70
|
| Rate for Payer: BCBS MT POS |
$249.85
|
| Rate for Payer: BCBS MT Traditional |
$263.00
|
| Rate for Payer: Cash Price |
$236.70
|
| Rate for Payer: Cigna Commercial |
$249.85
|
| Rate for Payer: Cigna Medicare |
$236.70
|
| Rate for Payer: Medicaid All Medicaid |
$241.96
|
| Rate for Payer: Medicare All Medicare |
$184.10
|
| Rate for Payer: Monida Allegiance |
$249.85
|
| Rate for Payer: Monida First Choice Health |
$255.11
|
| Rate for Payer: Monida Montana Health Co-op |
$249.85
|
| Rate for Payer: Monida PacificSource |
$249.85
|
|
|
CELIAC DSE COMPREHENSIVE CASCADE
|
Facility
|
IP
|
$263.00
|
|
|
Service Code
|
CPT 81376
|
| Hospital Charge Code |
4088007
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$184.10 |
| Max. Negotiated Rate |
$263.00 |
| Rate for Payer: Aetna Commercial |
$249.85
|
| Rate for Payer: Aetna Medicare |
$236.70
|
| Rate for Payer: BCBS MT CHIP |
$236.70
|
| Rate for Payer: BCBS MT Closed Plan Network |
$249.85
|
| Rate for Payer: BCBS MT HealthLink |
$236.70
|
| Rate for Payer: BCBS MT Medicare |
$236.70
|
| Rate for Payer: BCBS MT POS |
$249.85
|
| Rate for Payer: BCBS MT Traditional |
$263.00
|
| Rate for Payer: Cash Price |
$236.70
|
| Rate for Payer: Cigna Commercial |
$249.85
|
| Rate for Payer: Cigna Medicare |
$236.70
|
| Rate for Payer: Medicaid All Medicaid |
$241.96
|
| Rate for Payer: Medicare All Medicare |
$184.10
|
| Rate for Payer: Monida Allegiance |
$249.85
|
| Rate for Payer: Monida First Choice Health |
$255.11
|
| Rate for Payer: Monida Montana Health Co-op |
$249.85
|
| Rate for Payer: Monida PacificSource |
$249.85
|
|
