|
DICLOFENAC TAB DR [75 MG] NF
|
Facility
|
OP
|
$8.00
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
3000115
|
|
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
|
|
|
DICLOFENAC TOPICAL GEL [1 %] 50GM
|
Facility
|
IP
|
$61.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
3000116
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$42.70 |
| Max. Negotiated Rate |
$61.00 |
| Rate for Payer: Aetna Commercial |
$57.95
|
| Rate for Payer: Aetna Medicare |
$54.90
|
| Rate for Payer: BCBS MT CHIP |
$54.90
|
| Rate for Payer: BCBS MT Closed Plan Network |
$57.95
|
| Rate for Payer: BCBS MT HealthLink |
$54.90
|
| Rate for Payer: BCBS MT Medicare |
$54.90
|
| Rate for Payer: BCBS MT POS |
$57.95
|
| Rate for Payer: BCBS MT Traditional |
$61.00
|
| Rate for Payer: Cash Price |
$54.90
|
| Rate for Payer: Cigna Commercial |
$57.95
|
| Rate for Payer: Cigna Medicare |
$54.90
|
| Rate for Payer: Medicaid All Medicaid |
$56.12
|
| Rate for Payer: Medicare All Medicare |
$42.70
|
| Rate for Payer: Monida Allegiance |
$57.95
|
| Rate for Payer: Monida First Choice Health |
$59.17
|
| Rate for Payer: Monida Montana Health Co-op |
$57.95
|
| Rate for Payer: Monida PacificSource |
$57.95
|
|
|
DICLOFENAC TOPICAL GEL [1 %] 50GM
|
Facility
|
OP
|
$61.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
3000116
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$42.70 |
| Max. Negotiated Rate |
$61.00 |
| Rate for Payer: Aetna Commercial |
$57.95
|
| Rate for Payer: Aetna Medicare |
$54.90
|
| Rate for Payer: BCBS MT CHIP |
$54.90
|
| Rate for Payer: BCBS MT Closed Plan Network |
$57.95
|
| Rate for Payer: BCBS MT HealthLink |
$54.90
|
| Rate for Payer: BCBS MT Medicare |
$54.90
|
| Rate for Payer: BCBS MT POS |
$57.95
|
| Rate for Payer: BCBS MT Traditional |
$61.00
|
| Rate for Payer: Cash Price |
$54.90
|
| Rate for Payer: Cigna Commercial |
$57.95
|
| Rate for Payer: Cigna Medicare |
$54.90
|
| Rate for Payer: Medicaid All Medicaid |
$56.12
|
| Rate for Payer: Medicare All Medicare |
$42.70
|
| Rate for Payer: Monida Allegiance |
$57.95
|
| Rate for Payer: Monida First Choice Health |
$59.17
|
| Rate for Payer: Monida Montana Health Co-op |
$57.95
|
| Rate for Payer: Monida PacificSource |
$57.95
|
|
|
DICYCLOMINE CAP [10 MG] NF
|
Facility
|
OP
|
$8.00
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
3000117
|
|
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
|
|
|
DICYCLOMINE CAP [10 MG] NF
|
Facility
|
IP
|
$8.00
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
3000117
|
|
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
|
|
|
DICYCLOMINE LIQ [10 MG/5 ML]
|
Facility
|
IP
|
$5.00
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
3000118
|
|
Hospital Revenue Code
|
259
|
| 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
|
|
|
DICYCLOMINE LIQ [10 MG/5 ML]
|
Facility
|
OP
|
$5.00
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
3000118
|
|
Hospital Revenue Code
|
259
|
| 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
|
|
|
DIGITAL NERVE BLOCK PERIPHERAL NERVE
|
Facility
|
OP
|
$637.00
|
|
|
Service Code
|
CPT 64450
|
| Hospital Charge Code |
8064450
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$445.90 |
| Max. Negotiated Rate |
$637.00 |
| Rate for Payer: Aetna Commercial |
$605.15
|
| Rate for Payer: Aetna Medicare |
$573.30
|
| Rate for Payer: BCBS MT CHIP |
$573.30
|
| Rate for Payer: BCBS MT Closed Plan Network |
$605.15
|
| Rate for Payer: BCBS MT HealthLink |
$573.30
|
| Rate for Payer: BCBS MT Medicare |
$573.30
|
| Rate for Payer: BCBS MT POS |
$605.15
|
| Rate for Payer: BCBS MT Traditional |
$637.00
|
| Rate for Payer: Cash Price |
$573.30
|
| Rate for Payer: Cigna Commercial |
$605.15
|
| Rate for Payer: Cigna Medicare |
$573.30
|
| Rate for Payer: Medicaid All Medicaid |
$586.04
|
| Rate for Payer: Medicare All Medicare |
$445.90
|
| Rate for Payer: Monida Allegiance |
$605.15
|
| Rate for Payer: Monida First Choice Health |
$617.89
|
| Rate for Payer: Monida Montana Health Co-op |
$605.15
|
| Rate for Payer: Monida PacificSource |
$605.15
|
|
|
DIGITAL NERVE BLOCK PERIPHERAL NERVE
|
Facility
|
IP
|
$637.00
|
|
|
Service Code
|
CPT 64450
|
| Hospital Charge Code |
8064450
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$445.90 |
| Max. Negotiated Rate |
$637.00 |
| Rate for Payer: Aetna Commercial |
$605.15
|
| Rate for Payer: Aetna Medicare |
$573.30
|
| Rate for Payer: BCBS MT CHIP |
$573.30
|
| Rate for Payer: BCBS MT Closed Plan Network |
$605.15
|
| Rate for Payer: BCBS MT HealthLink |
$573.30
|
| Rate for Payer: BCBS MT Medicare |
$573.30
|
| Rate for Payer: BCBS MT POS |
$605.15
|
| Rate for Payer: BCBS MT Traditional |
$637.00
|
| Rate for Payer: Cash Price |
$573.30
|
| Rate for Payer: Cigna Commercial |
$605.15
|
| Rate for Payer: Cigna Medicare |
$573.30
|
| Rate for Payer: Medicaid All Medicaid |
$586.04
|
| Rate for Payer: Medicare All Medicare |
$445.90
|
| Rate for Payer: Monida Allegiance |
$605.15
|
| Rate for Payer: Monida First Choice Health |
$617.89
|
| Rate for Payer: Monida Montana Health Co-op |
$605.15
|
| Rate for Payer: Monida PacificSource |
$605.15
|
|
|
DIGOXIN
|
Facility
|
IP
|
$144.00
|
|
|
Service Code
|
CPT 80162
|
| Hospital Charge Code |
4080162
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$100.80 |
| Max. Negotiated Rate |
$144.00 |
| Rate for Payer: Aetna Commercial |
$136.80
|
| Rate for Payer: Aetna Medicare |
$129.60
|
| Rate for Payer: BCBS MT CHIP |
$129.60
|
| Rate for Payer: BCBS MT Closed Plan Network |
$136.80
|
| Rate for Payer: BCBS MT HealthLink |
$129.60
|
| Rate for Payer: BCBS MT Medicare |
$129.60
|
| Rate for Payer: BCBS MT POS |
$136.80
|
| Rate for Payer: BCBS MT Traditional |
$144.00
|
| Rate for Payer: Cash Price |
$129.60
|
| Rate for Payer: Cigna Commercial |
$136.80
|
| Rate for Payer: Cigna Medicare |
$129.60
|
| Rate for Payer: Medicaid All Medicaid |
$132.48
|
| Rate for Payer: Medicare All Medicare |
$100.80
|
| Rate for Payer: Monida Allegiance |
$136.80
|
| Rate for Payer: Monida First Choice Health |
$139.68
|
| Rate for Payer: Monida Montana Health Co-op |
$136.80
|
| Rate for Payer: Monida PacificSource |
$136.80
|
|
|
DIGOXIN
|
Facility
|
OP
|
$144.00
|
|
|
Service Code
|
CPT 80162
|
| Hospital Charge Code |
4080162
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$100.80 |
| Max. Negotiated Rate |
$144.00 |
| Rate for Payer: Aetna Commercial |
$136.80
|
| Rate for Payer: Aetna Medicare |
$129.60
|
| Rate for Payer: BCBS MT CHIP |
$129.60
|
| Rate for Payer: BCBS MT Closed Plan Network |
$136.80
|
| Rate for Payer: BCBS MT HealthLink |
$129.60
|
| Rate for Payer: BCBS MT Medicare |
$129.60
|
| Rate for Payer: BCBS MT POS |
$136.80
|
| Rate for Payer: BCBS MT Traditional |
$144.00
|
| Rate for Payer: Cash Price |
$129.60
|
| Rate for Payer: Cigna Commercial |
$136.80
|
| Rate for Payer: Cigna Medicare |
$129.60
|
| Rate for Payer: Medicaid All Medicaid |
$132.48
|
| Rate for Payer: Medicare All Medicare |
$100.80
|
| Rate for Payer: Monida Allegiance |
$136.80
|
| Rate for Payer: Monida First Choice Health |
$139.68
|
| Rate for Payer: Monida Montana Health Co-op |
$136.80
|
| Rate for Payer: Monida PacificSource |
$136.80
|
|
|
DIGOXIN INJ [500 MCG/2 ML]
|
Facility
|
OP
|
$24.00
|
|
|
Service Code
|
HCPCS J1160
|
| Hospital Charge Code |
3000119
|
|
Hospital Revenue Code
|
259
|
| 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
|
|
|
DIGOXIN INJ [500 MCG/2 ML]
|
Facility
|
IP
|
$24.00
|
|
|
Service Code
|
HCPCS J1160
|
| Hospital Charge Code |
3000119
|
|
Hospital Revenue Code
|
259
|
| 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
|
|
|
DIGOXIN TAB [0.125 MG]
|
Facility
|
IP
|
$8.00
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
3000120
|
|
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
|
|
|
DIGOXIN TAB [0.125 MG]
|
Facility
|
OP
|
$8.00
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
3000120
|
|
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
|
|
|
DIHYDROTESTOSTERONE (500142)
|
Facility
|
IP
|
$236.00
|
|
|
Service Code
|
CPT 82642
|
| Hospital Charge Code |
4082642
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$165.20 |
| Max. Negotiated Rate |
$236.00 |
| Rate for Payer: Aetna Commercial |
$224.20
|
| Rate for Payer: Aetna Medicare |
$212.40
|
| Rate for Payer: BCBS MT CHIP |
$212.40
|
| Rate for Payer: BCBS MT Closed Plan Network |
$224.20
|
| Rate for Payer: BCBS MT HealthLink |
$212.40
|
| Rate for Payer: BCBS MT Medicare |
$212.40
|
| Rate for Payer: BCBS MT POS |
$224.20
|
| Rate for Payer: BCBS MT Traditional |
$236.00
|
| Rate for Payer: Cash Price |
$212.40
|
| Rate for Payer: Cigna Commercial |
$224.20
|
| Rate for Payer: Cigna Medicare |
$212.40
|
| Rate for Payer: Medicaid All Medicaid |
$217.12
|
| Rate for Payer: Medicare All Medicare |
$165.20
|
| Rate for Payer: Monida Allegiance |
$224.20
|
| Rate for Payer: Monida First Choice Health |
$228.92
|
| Rate for Payer: Monida Montana Health Co-op |
$224.20
|
| Rate for Payer: Monida PacificSource |
$224.20
|
|
|
DIHYDROTESTOSTERONE (500142)
|
Facility
|
OP
|
$236.00
|
|
|
Service Code
|
CPT 82642
|
| Hospital Charge Code |
4082642
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$165.20 |
| Max. Negotiated Rate |
$236.00 |
| Rate for Payer: Aetna Commercial |
$224.20
|
| Rate for Payer: Aetna Medicare |
$212.40
|
| Rate for Payer: BCBS MT CHIP |
$212.40
|
| Rate for Payer: BCBS MT Closed Plan Network |
$224.20
|
| Rate for Payer: BCBS MT HealthLink |
$212.40
|
| Rate for Payer: BCBS MT Medicare |
$212.40
|
| Rate for Payer: BCBS MT POS |
$224.20
|
| Rate for Payer: BCBS MT Traditional |
$236.00
|
| Rate for Payer: Cash Price |
$212.40
|
| Rate for Payer: Cigna Commercial |
$224.20
|
| Rate for Payer: Cigna Medicare |
$212.40
|
| Rate for Payer: Medicaid All Medicaid |
$217.12
|
| Rate for Payer: Medicare All Medicare |
$165.20
|
| Rate for Payer: Monida Allegiance |
$224.20
|
| Rate for Payer: Monida First Choice Health |
$228.92
|
| Rate for Payer: Monida Montana Health Co-op |
$224.20
|
| Rate for Payer: Monida PacificSource |
$224.20
|
|
|
DILTIAZEM [60 MG] TAB NF
|
Facility
|
OP
|
$8.00
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
3000530
|
|
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
|
|
|
DILTIAZEM [60 MG] TAB NF
|
Facility
|
IP
|
$8.00
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
3000530
|
|
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
|
|
|
DILTIAZEM ER CAP [120 MG]
|
Facility
|
IP
|
$8.00
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
3000121
|
|
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
|
|
|
DILTIAZEM ER CAP [120 MG]
|
Facility
|
OP
|
$8.00
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
3000121
|
|
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
|
|
|
DILTIAZEM ER CAP [180 MG] NF
|
Facility
|
OP
|
$8.00
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
3000122
|
|
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
|
|
|
DILTIAZEM ER CAP [180 MG] NF
|
Facility
|
IP
|
$8.00
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
3000122
|
|
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
|
|
|
DILTIAZEM INJ [25 MG/5 ML]
|
Facility
|
IP
|
$26.00
|
|
|
Service Code
|
HCPCS J1163
|
| Hospital Charge Code |
3000123
|
|
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
|
|
|
DILTIAZEM INJ [25 MG/5 ML]
|
Facility
|
OP
|
$26.00
|
|
|
Service Code
|
HCPCS J1163
|
| Hospital Charge Code |
3000123
|
|
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
|
|
