|
OP MOD CON SEDATION ADDTL 15 MIN 99153
|
Facility
IP
|
$122.00
|
|
|
Service Code
|
CPT 99153
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
370
|
| Min. Negotiated Rate |
$85.40 |
| Max. Negotiated Rate |
$122.00 |
| Rate for Payer: AETNA Commercial |
$115.90
|
| Rate for Payer: AETNA Medicare |
$109.80
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$115.90
|
| Rate for Payer: BCBS Healthlink |
$109.80
|
| Rate for Payer: BCBS HMK CHIP |
$109.80
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$109.80
|
| Rate for Payer: BCBS POS |
$115.90
|
| Rate for Payer: BCBS Traditional |
$122.00
|
| Rate for Payer: CASH_PRICE |
$97.60
|
| Rate for Payer: CIGNA Commercial |
$115.90
|
| Rate for Payer: CIGNA Medicare |
$109.80
|
| Rate for Payer: HUMANA Commercial |
$109.80
|
| Rate for Payer: MEDICAID Medicaid |
$112.24
|
| Rate for Payer: MEDICARE Medicare |
$85.40
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$115.90
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$118.34
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$115.90
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$115.90
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$103.70
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$97.60
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$97.60
|
|
|
OP MOD CON SEDATION ADDTL 15 MIN 99153
|
Facility
OP
|
$122.00
|
|
|
Service Code
|
CPT 99153
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
370
|
| Min. Negotiated Rate |
$85.40 |
| Max. Negotiated Rate |
$122.00 |
| Rate for Payer: AETNA Commercial |
$115.90
|
| Rate for Payer: AETNA Medicare |
$109.80
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$115.90
|
| Rate for Payer: BCBS Healthlink |
$109.80
|
| Rate for Payer: BCBS HMK CHIP |
$109.80
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$109.80
|
| Rate for Payer: BCBS POS |
$115.90
|
| Rate for Payer: BCBS Traditional |
$122.00
|
| Rate for Payer: CASH_PRICE |
$97.60
|
| Rate for Payer: CIGNA Commercial |
$115.90
|
| Rate for Payer: CIGNA Medicare |
$109.80
|
| Rate for Payer: HUMANA Commercial |
$109.80
|
| Rate for Payer: MEDICAID Medicaid |
$112.24
|
| Rate for Payer: MEDICARE Medicare |
$85.40
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$115.90
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$118.34
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$115.90
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$115.90
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$103.70
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$97.60
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$97.60
|
|
|
OPO DIRECT ADMISSION
|
Facility
IP
|
$186.00
|
|
|
Service Code
|
CPT G0379
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
762
|
| Min. Negotiated Rate |
$130.20 |
| Max. Negotiated Rate |
$186.00 |
| Rate for Payer: AETNA Commercial |
$176.70
|
| Rate for Payer: AETNA Medicare |
$167.40
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$176.70
|
| Rate for Payer: BCBS Healthlink |
$167.40
|
| Rate for Payer: BCBS HMK CHIP |
$167.40
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$167.40
|
| Rate for Payer: BCBS POS |
$176.70
|
| Rate for Payer: BCBS Traditional |
$186.00
|
| Rate for Payer: CASH_PRICE |
$148.80
|
| Rate for Payer: CIGNA Commercial |
$176.70
|
| Rate for Payer: CIGNA Medicare |
$167.40
|
| Rate for Payer: HUMANA Commercial |
$167.40
|
| Rate for Payer: MEDICAID Medicaid |
$171.12
|
| Rate for Payer: MEDICARE Medicare |
$130.20
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$176.70
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$180.42
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$176.70
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$176.70
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$158.10
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$148.80
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$148.80
|
|
|
OPO DIRECT ADMISSION
|
Facility
OP
|
$186.00
|
|
|
Service Code
|
CPT G0379
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
762
|
| Min. Negotiated Rate |
$130.20 |
| Max. Negotiated Rate |
$186.00 |
| Rate for Payer: AETNA Commercial |
$176.70
|
| Rate for Payer: AETNA Medicare |
$167.40
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$176.70
|
| Rate for Payer: BCBS Healthlink |
$167.40
|
| Rate for Payer: BCBS HMK CHIP |
$167.40
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$167.40
|
| Rate for Payer: BCBS POS |
$176.70
|
| Rate for Payer: BCBS Traditional |
$186.00
|
| Rate for Payer: CASH_PRICE |
$148.80
|
| Rate for Payer: CIGNA Commercial |
$176.70
|
| Rate for Payer: CIGNA Medicare |
$167.40
|
| Rate for Payer: HUMANA Commercial |
$167.40
|
| Rate for Payer: MEDICAID Medicaid |
$171.12
|
| Rate for Payer: MEDICARE Medicare |
$130.20
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$176.70
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$180.42
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$176.70
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$176.70
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$158.10
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$148.80
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$148.80
|
|
|
OPO FIRST HOUR
|
Facility
OP
|
$186.00
|
|
|
Service Code
|
CPT G0378
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
762
|
| Min. Negotiated Rate |
$130.20 |
| Max. Negotiated Rate |
$186.00 |
| Rate for Payer: AETNA Commercial |
$176.70
|
| Rate for Payer: AETNA Medicare |
$167.40
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$176.70
|
| Rate for Payer: BCBS Healthlink |
$167.40
|
| Rate for Payer: BCBS HMK CHIP |
$167.40
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$167.40
|
| Rate for Payer: BCBS POS |
$176.70
|
| Rate for Payer: BCBS Traditional |
$186.00
|
| Rate for Payer: CASH_PRICE |
$148.80
|
| Rate for Payer: CIGNA Commercial |
$176.70
|
| Rate for Payer: CIGNA Medicare |
$167.40
|
| Rate for Payer: HUMANA Commercial |
$167.40
|
| Rate for Payer: MEDICAID Medicaid |
$171.12
|
| Rate for Payer: MEDICARE Medicare |
$130.20
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$176.70
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$180.42
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$176.70
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$176.70
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$158.10
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$148.80
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$148.80
|
|
|
OPO FIRST HOUR
|
Facility
IP
|
$186.00
|
|
|
Service Code
|
CPT G0378
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
762
|
| Min. Negotiated Rate |
$130.20 |
| Max. Negotiated Rate |
$186.00 |
| Rate for Payer: AETNA Commercial |
$176.70
|
| Rate for Payer: AETNA Medicare |
$167.40
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$176.70
|
| Rate for Payer: BCBS Healthlink |
$167.40
|
| Rate for Payer: BCBS HMK CHIP |
$167.40
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$167.40
|
| Rate for Payer: BCBS POS |
$176.70
|
| Rate for Payer: BCBS Traditional |
$186.00
|
| Rate for Payer: CASH_PRICE |
$148.80
|
| Rate for Payer: CIGNA Commercial |
$176.70
|
| Rate for Payer: CIGNA Medicare |
$167.40
|
| Rate for Payer: HUMANA Commercial |
$167.40
|
| Rate for Payer: MEDICAID Medicaid |
$171.12
|
| Rate for Payer: MEDICARE Medicare |
$130.20
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$176.70
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$180.42
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$176.70
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$176.70
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$158.10
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$148.80
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$148.80
|
|
|
OPO PER HOUR 2 OR MORE
|
Facility
IP
|
$49.00
|
|
|
Service Code
|
CPT G0378
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
762
|
| Min. Negotiated Rate |
$34.30 |
| Max. Negotiated Rate |
$49.00 |
| Rate for Payer: AETNA Commercial |
$46.55
|
| Rate for Payer: AETNA Medicare |
$44.10
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$46.55
|
| Rate for Payer: BCBS Healthlink |
$44.10
|
| Rate for Payer: BCBS HMK CHIP |
$44.10
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$44.10
|
| Rate for Payer: BCBS POS |
$46.55
|
| Rate for Payer: BCBS Traditional |
$49.00
|
| Rate for Payer: CASH_PRICE |
$39.20
|
| Rate for Payer: CIGNA Commercial |
$46.55
|
| Rate for Payer: CIGNA Medicare |
$44.10
|
| Rate for Payer: HUMANA Commercial |
$44.10
|
| Rate for Payer: MEDICAID Medicaid |
$45.08
|
| Rate for Payer: MEDICARE Medicare |
$34.30
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$46.55
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$47.53
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$46.55
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$46.55
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$41.65
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$39.20
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$39.20
|
|
|
OPO PER HOUR 2 OR MORE
|
Facility
OP
|
$49.00
|
|
|
Service Code
|
CPT G0378
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
762
|
| Min. Negotiated Rate |
$34.30 |
| Max. Negotiated Rate |
$49.00 |
| Rate for Payer: AETNA Commercial |
$46.55
|
| Rate for Payer: AETNA Medicare |
$44.10
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$46.55
|
| Rate for Payer: BCBS Healthlink |
$44.10
|
| Rate for Payer: BCBS HMK CHIP |
$44.10
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$44.10
|
| Rate for Payer: BCBS POS |
$46.55
|
| Rate for Payer: BCBS Traditional |
$49.00
|
| Rate for Payer: CASH_PRICE |
$39.20
|
| Rate for Payer: CIGNA Commercial |
$46.55
|
| Rate for Payer: CIGNA Medicare |
$44.10
|
| Rate for Payer: HUMANA Commercial |
$44.10
|
| Rate for Payer: MEDICAID Medicaid |
$45.08
|
| Rate for Payer: MEDICARE Medicare |
$34.30
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$46.55
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$47.53
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$46.55
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$46.55
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$41.65
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$39.20
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$39.20
|
|
|
OP- PM MOD CONCSED >5 YR 1ST 15MIN 99152
|
Facility
OP
|
$312.00
|
|
|
Service Code
|
CPT 99152
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
370
|
| Min. Negotiated Rate |
$218.40 |
| Max. Negotiated Rate |
$312.00 |
| Rate for Payer: AETNA Commercial |
$296.40
|
| Rate for Payer: AETNA Medicare |
$280.80
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$296.40
|
| Rate for Payer: BCBS Healthlink |
$280.80
|
| Rate for Payer: BCBS HMK CHIP |
$280.80
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$280.80
|
| Rate for Payer: BCBS POS |
$296.40
|
| Rate for Payer: BCBS Traditional |
$312.00
|
| Rate for Payer: CASH_PRICE |
$249.60
|
| Rate for Payer: CIGNA Commercial |
$296.40
|
| Rate for Payer: CIGNA Medicare |
$280.80
|
| Rate for Payer: HUMANA Commercial |
$280.80
|
| Rate for Payer: MEDICAID Medicaid |
$287.04
|
| Rate for Payer: MEDICARE Medicare |
$218.40
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$296.40
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$302.64
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$296.40
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$296.40
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$265.20
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$249.60
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$249.60
|
|
|
OP- PM MOD CONCSED >5 YR 1ST 15MIN 99152
|
Facility
IP
|
$312.00
|
|
|
Service Code
|
CPT 99152
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
370
|
| Min. Negotiated Rate |
$218.40 |
| Max. Negotiated Rate |
$312.00 |
| Rate for Payer: AETNA Commercial |
$296.40
|
| Rate for Payer: AETNA Medicare |
$280.80
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$296.40
|
| Rate for Payer: BCBS Healthlink |
$280.80
|
| Rate for Payer: BCBS HMK CHIP |
$280.80
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$280.80
|
| Rate for Payer: BCBS POS |
$296.40
|
| Rate for Payer: BCBS Traditional |
$312.00
|
| Rate for Payer: CASH_PRICE |
$249.60
|
| Rate for Payer: CIGNA Commercial |
$296.40
|
| Rate for Payer: CIGNA Medicare |
$280.80
|
| Rate for Payer: HUMANA Commercial |
$280.80
|
| Rate for Payer: MEDICAID Medicaid |
$287.04
|
| Rate for Payer: MEDICARE Medicare |
$218.40
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$296.40
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$302.64
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$296.40
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$296.40
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$265.20
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$249.60
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$249.60
|
|
|
OP PRO FEE INJ ANE AGEN AXILLARY
|
Facility
OP
|
$499.00
|
|
|
Service Code
|
CPT 64417 GF
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
969
|
| Min. Negotiated Rate |
$349.30 |
| Max. Negotiated Rate |
$499.00 |
| Rate for Payer: AETNA Commercial |
$474.05
|
| Rate for Payer: AETNA Medicare |
$449.10
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$474.05
|
| Rate for Payer: BCBS Healthlink |
$449.10
|
| Rate for Payer: BCBS HMK CHIP |
$449.10
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$449.10
|
| Rate for Payer: BCBS POS |
$474.05
|
| Rate for Payer: BCBS Traditional |
$499.00
|
| Rate for Payer: CASH_PRICE |
$399.20
|
| Rate for Payer: CIGNA Commercial |
$474.05
|
| Rate for Payer: CIGNA Medicare |
$449.10
|
| Rate for Payer: HUMANA Commercial |
$449.10
|
| Rate for Payer: MEDICAID Medicaid |
$459.08
|
| Rate for Payer: MEDICARE Medicare |
$349.30
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$474.05
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$484.03
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$474.05
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$474.05
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$424.15
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$399.20
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$399.20
|
|
|
OP PRO FEE INJ ANE AGEN AXILLARY
|
Facility
IP
|
$499.00
|
|
|
Service Code
|
CPT 64417 GF
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
969
|
| Min. Negotiated Rate |
$349.30 |
| Max. Negotiated Rate |
$499.00 |
| Rate for Payer: AETNA Commercial |
$474.05
|
| Rate for Payer: AETNA Medicare |
$449.10
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$474.05
|
| Rate for Payer: BCBS Healthlink |
$449.10
|
| Rate for Payer: BCBS HMK CHIP |
$449.10
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$449.10
|
| Rate for Payer: BCBS POS |
$474.05
|
| Rate for Payer: BCBS Traditional |
$499.00
|
| Rate for Payer: CASH_PRICE |
$399.20
|
| Rate for Payer: CIGNA Commercial |
$474.05
|
| Rate for Payer: CIGNA Medicare |
$449.10
|
| Rate for Payer: HUMANA Commercial |
$449.10
|
| Rate for Payer: MEDICAID Medicaid |
$459.08
|
| Rate for Payer: MEDICARE Medicare |
$349.30
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$474.05
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$484.03
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$474.05
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$474.05
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$424.15
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$399.20
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$399.20
|
|
|
OPSITE DRESSING 5.5X4
|
Facility
IP
|
$13.00
|
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
270
|
| 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 CLOSED PLAN NETWORK |
$12.35
|
| Rate for Payer: BCBS Healthlink |
$11.70
|
| Rate for Payer: BCBS HMK CHIP |
$11.70
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$11.70
|
| Rate for Payer: BCBS POS |
$12.35
|
| Rate for Payer: BCBS Traditional |
$13.00
|
| Rate for Payer: CASH_PRICE |
$10.40
|
| Rate for Payer: CIGNA Commercial |
$12.35
|
| Rate for Payer: CIGNA Medicare |
$11.70
|
| Rate for Payer: HUMANA Commercial |
$11.70
|
| Rate for Payer: MEDICAID Medicaid |
$11.96
|
| Rate for Payer: MEDICARE Medicare |
$9.10
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$12.35
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$12.61
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$12.35
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$12.35
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$11.05
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$10.40
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$10.40
|
|
|
OPSITE DRESSING 5.5X4
|
Facility
OP
|
$13.00
|
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
270
|
| 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 CLOSED PLAN NETWORK |
$12.35
|
| Rate for Payer: BCBS Healthlink |
$11.70
|
| Rate for Payer: BCBS HMK CHIP |
$11.70
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$11.70
|
| Rate for Payer: BCBS POS |
$12.35
|
| Rate for Payer: BCBS Traditional |
$13.00
|
| Rate for Payer: CASH_PRICE |
$10.40
|
| Rate for Payer: CIGNA Commercial |
$12.35
|
| Rate for Payer: CIGNA Medicare |
$11.70
|
| Rate for Payer: HUMANA Commercial |
$11.70
|
| Rate for Payer: MEDICAID Medicaid |
$11.96
|
| Rate for Payer: MEDICARE Medicare |
$9.10
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$12.35
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$12.61
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$12.35
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$12.35
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$11.05
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$10.40
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$10.40
|
|
|
OPTIFOAM 4X4 ADHESIVE
|
Facility
OP
|
$36.00
|
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$25.20 |
| Max. Negotiated Rate |
$36.00 |
| Rate for Payer: AETNA Commercial |
$34.20
|
| Rate for Payer: AETNA Medicare |
$32.40
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$34.20
|
| Rate for Payer: BCBS Healthlink |
$32.40
|
| Rate for Payer: BCBS HMK CHIP |
$32.40
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$32.40
|
| Rate for Payer: BCBS POS |
$34.20
|
| Rate for Payer: BCBS Traditional |
$36.00
|
| Rate for Payer: CASH_PRICE |
$28.80
|
| Rate for Payer: CIGNA Commercial |
$34.20
|
| Rate for Payer: CIGNA Medicare |
$32.40
|
| Rate for Payer: HUMANA Commercial |
$32.40
|
| Rate for Payer: MEDICAID Medicaid |
$33.12
|
| Rate for Payer: MEDICARE Medicare |
$25.20
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$34.20
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$34.92
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$34.20
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$34.20
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$30.60
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$28.80
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$28.80
|
|
|
OPTIFOAM 4X4 ADHESIVE
|
Facility
IP
|
$36.00
|
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$25.20 |
| Max. Negotiated Rate |
$36.00 |
| Rate for Payer: AETNA Commercial |
$34.20
|
| Rate for Payer: AETNA Medicare |
$32.40
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$34.20
|
| Rate for Payer: BCBS Healthlink |
$32.40
|
| Rate for Payer: BCBS HMK CHIP |
$32.40
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$32.40
|
| Rate for Payer: BCBS POS |
$34.20
|
| Rate for Payer: BCBS Traditional |
$36.00
|
| Rate for Payer: CASH_PRICE |
$28.80
|
| Rate for Payer: CIGNA Commercial |
$34.20
|
| Rate for Payer: CIGNA Medicare |
$32.40
|
| Rate for Payer: HUMANA Commercial |
$32.40
|
| Rate for Payer: MEDICAID Medicaid |
$33.12
|
| Rate for Payer: MEDICARE Medicare |
$25.20
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$34.20
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$34.92
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$34.20
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$34.20
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$30.60
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$28.80
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$28.80
|
|
|
OPTIFOAM 8X8
|
Facility
OP
|
$36.00
|
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$25.20 |
| Max. Negotiated Rate |
$36.00 |
| Rate for Payer: AETNA Commercial |
$34.20
|
| Rate for Payer: AETNA Medicare |
$32.40
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$34.20
|
| Rate for Payer: BCBS Healthlink |
$32.40
|
| Rate for Payer: BCBS HMK CHIP |
$32.40
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$32.40
|
| Rate for Payer: BCBS POS |
$34.20
|
| Rate for Payer: BCBS Traditional |
$36.00
|
| Rate for Payer: CASH_PRICE |
$28.80
|
| Rate for Payer: CIGNA Commercial |
$34.20
|
| Rate for Payer: CIGNA Medicare |
$32.40
|
| Rate for Payer: HUMANA Commercial |
$32.40
|
| Rate for Payer: MEDICAID Medicaid |
$33.12
|
| Rate for Payer: MEDICARE Medicare |
$25.20
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$34.20
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$34.92
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$34.20
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$34.20
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$30.60
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$28.80
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$28.80
|
|
|
OPTIFOAM 8X8
|
Facility
IP
|
$36.00
|
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$25.20 |
| Max. Negotiated Rate |
$36.00 |
| Rate for Payer: AETNA Commercial |
$34.20
|
| Rate for Payer: AETNA Medicare |
$32.40
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$34.20
|
| Rate for Payer: BCBS Healthlink |
$32.40
|
| Rate for Payer: BCBS HMK CHIP |
$32.40
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$32.40
|
| Rate for Payer: BCBS POS |
$34.20
|
| Rate for Payer: BCBS Traditional |
$36.00
|
| Rate for Payer: CASH_PRICE |
$28.80
|
| Rate for Payer: CIGNA Commercial |
$34.20
|
| Rate for Payer: CIGNA Medicare |
$32.40
|
| Rate for Payer: HUMANA Commercial |
$32.40
|
| Rate for Payer: MEDICAID Medicaid |
$33.12
|
| Rate for Payer: MEDICARE Medicare |
$25.20
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$34.20
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$34.92
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$34.20
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$34.20
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$30.60
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$28.80
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$28.80
|
|
|
OPTIPORE SPONGE
|
Facility
OP
|
$9.00
|
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
270
|
| 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 CLOSED PLAN NETWORK |
$8.55
|
| Rate for Payer: BCBS Healthlink |
$8.10
|
| Rate for Payer: BCBS HMK CHIP |
$8.10
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$8.10
|
| Rate for Payer: BCBS POS |
$8.55
|
| Rate for Payer: BCBS Traditional |
$9.00
|
| Rate for Payer: CASH_PRICE |
$7.20
|
| Rate for Payer: CIGNA Commercial |
$8.55
|
| Rate for Payer: CIGNA Medicare |
$8.10
|
| Rate for Payer: HUMANA Commercial |
$8.10
|
| Rate for Payer: MEDICAID Medicaid |
$8.28
|
| Rate for Payer: MEDICARE Medicare |
$6.30
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$8.55
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$8.73
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$8.55
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$8.55
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$7.65
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$7.20
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$7.20
|
|
|
OPTIPORE SPONGE
|
Facility
IP
|
$9.00
|
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
270
|
| 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 CLOSED PLAN NETWORK |
$8.55
|
| Rate for Payer: BCBS Healthlink |
$8.10
|
| Rate for Payer: BCBS HMK CHIP |
$8.10
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$8.10
|
| Rate for Payer: BCBS POS |
$8.55
|
| Rate for Payer: BCBS Traditional |
$9.00
|
| Rate for Payer: CASH_PRICE |
$7.20
|
| Rate for Payer: CIGNA Commercial |
$8.55
|
| Rate for Payer: CIGNA Medicare |
$8.10
|
| Rate for Payer: HUMANA Commercial |
$8.10
|
| Rate for Payer: MEDICAID Medicaid |
$8.28
|
| Rate for Payer: MEDICARE Medicare |
$6.30
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$8.55
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$8.73
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$8.55
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$8.55
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$7.65
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$7.20
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$7.20
|
|
|
ORAL AIRWAY # 12 120MM
|
Facility
IP
|
$4.00
|
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$2.80 |
| Max. Negotiated Rate |
$4.00 |
| Rate for Payer: AETNA Commercial |
$3.80
|
| Rate for Payer: AETNA Medicare |
$3.60
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$3.80
|
| Rate for Payer: BCBS Healthlink |
$3.60
|
| Rate for Payer: BCBS HMK CHIP |
$3.60
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$3.60
|
| Rate for Payer: BCBS POS |
$3.80
|
| Rate for Payer: BCBS Traditional |
$4.00
|
| Rate for Payer: CASH_PRICE |
$3.20
|
| Rate for Payer: CIGNA Commercial |
$3.80
|
| Rate for Payer: CIGNA Medicare |
$3.60
|
| Rate for Payer: HUMANA Commercial |
$3.60
|
| Rate for Payer: MEDICAID Medicaid |
$3.68
|
| Rate for Payer: MEDICARE Medicare |
$2.80
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$3.80
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$3.88
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$3.80
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$3.80
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$3.40
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$3.20
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$3.20
|
|
|
ORAL AIRWAY # 12 120MM
|
Facility
OP
|
$4.00
|
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$2.80 |
| Max. Negotiated Rate |
$4.00 |
| Rate for Payer: AETNA Commercial |
$3.80
|
| Rate for Payer: AETNA Medicare |
$3.60
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$3.80
|
| Rate for Payer: BCBS Healthlink |
$3.60
|
| Rate for Payer: BCBS HMK CHIP |
$3.60
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$3.60
|
| Rate for Payer: BCBS POS |
$3.80
|
| Rate for Payer: BCBS Traditional |
$4.00
|
| Rate for Payer: CASH_PRICE |
$3.20
|
| Rate for Payer: CIGNA Commercial |
$3.80
|
| Rate for Payer: CIGNA Medicare |
$3.60
|
| Rate for Payer: HUMANA Commercial |
$3.60
|
| Rate for Payer: MEDICAID Medicaid |
$3.68
|
| Rate for Payer: MEDICARE Medicare |
$2.80
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$3.80
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$3.88
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$3.80
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$3.80
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$3.40
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$3.20
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$3.20
|
|
|
OSELTAMIVIR CAP[30MG]
|
Facility
IP
|
$48.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$33.60 |
| Max. Negotiated Rate |
$48.00 |
| Rate for Payer: AETNA Commercial |
$45.60
|
| Rate for Payer: AETNA Medicare |
$43.20
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$45.60
|
| Rate for Payer: BCBS Healthlink |
$43.20
|
| Rate for Payer: BCBS HMK CHIP |
$43.20
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$43.20
|
| Rate for Payer: BCBS POS |
$45.60
|
| Rate for Payer: BCBS Traditional |
$48.00
|
| Rate for Payer: CASH_PRICE |
$38.40
|
| Rate for Payer: CIGNA Commercial |
$45.60
|
| Rate for Payer: CIGNA Medicare |
$43.20
|
| Rate for Payer: HUMANA Commercial |
$43.20
|
| Rate for Payer: MEDICAID Medicaid |
$44.16
|
| Rate for Payer: MEDICARE Medicare |
$33.60
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$45.60
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$46.56
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$45.60
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$45.60
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$40.80
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$38.40
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$38.40
|
|
|
OSELTAMIVIR CAP[30MG]
|
Facility
OP
|
$48.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$33.60 |
| Max. Negotiated Rate |
$48.00 |
| Rate for Payer: AETNA Commercial |
$45.60
|
| Rate for Payer: AETNA Medicare |
$43.20
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$45.60
|
| Rate for Payer: BCBS Healthlink |
$43.20
|
| Rate for Payer: BCBS HMK CHIP |
$43.20
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$43.20
|
| Rate for Payer: BCBS POS |
$45.60
|
| Rate for Payer: BCBS Traditional |
$48.00
|
| Rate for Payer: CASH_PRICE |
$38.40
|
| Rate for Payer: CIGNA Commercial |
$45.60
|
| Rate for Payer: CIGNA Medicare |
$43.20
|
| Rate for Payer: HUMANA Commercial |
$43.20
|
| Rate for Payer: MEDICAID Medicaid |
$44.16
|
| Rate for Payer: MEDICARE Medicare |
$33.60
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$45.60
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$46.56
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$45.60
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$45.60
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$40.80
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$38.40
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$38.40
|
|
|
OSELTAMIVIR CAP [75 MG]
|
Facility
OP
|
$52.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$36.40 |
| Max. Negotiated Rate |
$52.00 |
| Rate for Payer: AETNA Commercial |
$49.40
|
| Rate for Payer: AETNA Medicare |
$46.80
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$49.40
|
| Rate for Payer: BCBS Healthlink |
$46.80
|
| Rate for Payer: BCBS HMK CHIP |
$46.80
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$46.80
|
| Rate for Payer: BCBS POS |
$49.40
|
| Rate for Payer: BCBS Traditional |
$52.00
|
| Rate for Payer: CASH_PRICE |
$41.60
|
| Rate for Payer: CIGNA Commercial |
$49.40
|
| Rate for Payer: CIGNA Medicare |
$46.80
|
| Rate for Payer: HUMANA Commercial |
$46.80
|
| Rate for Payer: MEDICAID Medicaid |
$47.84
|
| Rate for Payer: MEDICARE Medicare |
$36.40
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$49.40
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$50.44
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$49.40
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$49.40
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$44.20
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$41.60
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$41.60
|
|
