|
ROTAVIRUS ORAL -ROTARIX (2DOSE)
|
Facility
OP
|
$522.00
|
|
|
Service Code
|
CPT 90681
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$365.40 |
| Max. Negotiated Rate |
$522.00 |
| Rate for Payer: AETNA Commercial |
$495.90
|
| Rate for Payer: AETNA Medicare |
$469.80
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$495.90
|
| Rate for Payer: BCBS Healthlink |
$469.80
|
| Rate for Payer: BCBS HMK CHIP |
$469.80
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$469.80
|
| Rate for Payer: BCBS POS |
$495.90
|
| Rate for Payer: BCBS Traditional |
$522.00
|
| Rate for Payer: CASH_PRICE |
$417.60
|
| Rate for Payer: CIGNA Commercial |
$495.90
|
| Rate for Payer: CIGNA Medicare |
$469.80
|
| Rate for Payer: HUMANA Commercial |
$469.80
|
| Rate for Payer: MEDICAID Medicaid |
$480.24
|
| Rate for Payer: MEDICARE Medicare |
$365.40
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$495.90
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$506.34
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$495.90
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$495.90
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$443.70
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$417.60
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$417.60
|
|
|
ROTAVIRUS ORAL - ROTATEQ (3DOSE)
|
Facility
IP
|
$139.00
|
|
|
Service Code
|
CPT 90680
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$97.30 |
| Max. Negotiated Rate |
$139.00 |
| Rate for Payer: AETNA Commercial |
$132.05
|
| Rate for Payer: AETNA Medicare |
$125.10
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$132.05
|
| Rate for Payer: BCBS Healthlink |
$125.10
|
| Rate for Payer: BCBS HMK CHIP |
$125.10
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$125.10
|
| Rate for Payer: BCBS POS |
$132.05
|
| Rate for Payer: BCBS Traditional |
$139.00
|
| Rate for Payer: CASH_PRICE |
$111.20
|
| Rate for Payer: CIGNA Commercial |
$132.05
|
| Rate for Payer: CIGNA Medicare |
$125.10
|
| Rate for Payer: HUMANA Commercial |
$125.10
|
| Rate for Payer: MEDICAID Medicaid |
$127.88
|
| Rate for Payer: MEDICARE Medicare |
$97.30
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$132.05
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$134.83
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$132.05
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$132.05
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$118.15
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$111.20
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$111.20
|
|
|
ROTAVIRUS ORAL - ROTATEQ (3DOSE)
|
Facility
OP
|
$139.00
|
|
|
Service Code
|
CPT 90680
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$97.30 |
| Max. Negotiated Rate |
$139.00 |
| Rate for Payer: AETNA Commercial |
$132.05
|
| Rate for Payer: AETNA Medicare |
$125.10
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$132.05
|
| Rate for Payer: BCBS Healthlink |
$125.10
|
| Rate for Payer: BCBS HMK CHIP |
$125.10
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$125.10
|
| Rate for Payer: BCBS POS |
$132.05
|
| Rate for Payer: BCBS Traditional |
$139.00
|
| Rate for Payer: CASH_PRICE |
$111.20
|
| Rate for Payer: CIGNA Commercial |
$132.05
|
| Rate for Payer: CIGNA Medicare |
$125.10
|
| Rate for Payer: HUMANA Commercial |
$125.10
|
| Rate for Payer: MEDICAID Medicaid |
$127.88
|
| Rate for Payer: MEDICARE Medicare |
$97.30
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$132.05
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$134.83
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$132.05
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$132.05
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$118.15
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$111.20
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$111.20
|
|
|
RPR, QUALITATIVE (006072)
|
Facility
OP
|
$11.00
|
|
|
Service Code
|
CPT 86592
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$7.70 |
| Max. Negotiated Rate |
$11.00 |
| Rate for Payer: AETNA Commercial |
$10.45
|
| Rate for Payer: AETNA Medicare |
$9.90
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$10.45
|
| Rate for Payer: BCBS Healthlink |
$9.90
|
| Rate for Payer: BCBS HMK CHIP |
$9.90
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$9.90
|
| Rate for Payer: BCBS POS |
$10.45
|
| Rate for Payer: BCBS Traditional |
$11.00
|
| Rate for Payer: CASH_PRICE |
$8.80
|
| Rate for Payer: CIGNA Commercial |
$10.45
|
| Rate for Payer: CIGNA Medicare |
$9.90
|
| Rate for Payer: HUMANA Commercial |
$9.90
|
| Rate for Payer: MEDICAID Medicaid |
$10.12
|
| Rate for Payer: MEDICARE Medicare |
$7.70
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$10.45
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$10.67
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$10.45
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$10.45
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$9.35
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$8.80
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$8.80
|
|
|
RPR, QUALITATIVE (006072)
|
Facility
IP
|
$11.00
|
|
|
Service Code
|
CPT 86592
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$7.70 |
| Max. Negotiated Rate |
$11.00 |
| Rate for Payer: AETNA Commercial |
$10.45
|
| Rate for Payer: AETNA Medicare |
$9.90
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$10.45
|
| Rate for Payer: BCBS Healthlink |
$9.90
|
| Rate for Payer: BCBS HMK CHIP |
$9.90
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$9.90
|
| Rate for Payer: BCBS POS |
$10.45
|
| Rate for Payer: BCBS Traditional |
$11.00
|
| Rate for Payer: CASH_PRICE |
$8.80
|
| Rate for Payer: CIGNA Commercial |
$10.45
|
| Rate for Payer: CIGNA Medicare |
$9.90
|
| Rate for Payer: HUMANA Commercial |
$9.90
|
| Rate for Payer: MEDICAID Medicaid |
$10.12
|
| Rate for Payer: MEDICARE Medicare |
$7.70
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$10.45
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$10.67
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$10.45
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$10.45
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$9.35
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$8.80
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$8.80
|
|
|
RSV, RAPID TEST
|
Facility
IP
|
$125.00
|
|
|
Service Code
|
CPT 87807
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$87.50 |
| Max. Negotiated Rate |
$125.00 |
| Rate for Payer: AETNA Commercial |
$118.75
|
| Rate for Payer: AETNA Medicare |
$112.50
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$118.75
|
| Rate for Payer: BCBS Healthlink |
$112.50
|
| Rate for Payer: BCBS HMK CHIP |
$112.50
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$112.50
|
| Rate for Payer: BCBS POS |
$118.75
|
| Rate for Payer: BCBS Traditional |
$125.00
|
| Rate for Payer: CASH_PRICE |
$100.00
|
| Rate for Payer: CIGNA Commercial |
$118.75
|
| Rate for Payer: CIGNA Medicare |
$112.50
|
| Rate for Payer: HUMANA Commercial |
$112.50
|
| Rate for Payer: MEDICAID Medicaid |
$115.00
|
| Rate for Payer: MEDICARE Medicare |
$87.50
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$118.75
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$121.25
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$118.75
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$118.75
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$106.25
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$100.00
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$100.00
|
|
|
RSV, RAPID TEST
|
Facility
OP
|
$125.00
|
|
|
Service Code
|
CPT 87807
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$87.50 |
| Max. Negotiated Rate |
$125.00 |
| Rate for Payer: AETNA Commercial |
$118.75
|
| Rate for Payer: AETNA Medicare |
$112.50
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$118.75
|
| Rate for Payer: BCBS Healthlink |
$112.50
|
| Rate for Payer: BCBS HMK CHIP |
$112.50
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$112.50
|
| Rate for Payer: BCBS POS |
$118.75
|
| Rate for Payer: BCBS Traditional |
$125.00
|
| Rate for Payer: CASH_PRICE |
$100.00
|
| Rate for Payer: CIGNA Commercial |
$118.75
|
| Rate for Payer: CIGNA Medicare |
$112.50
|
| Rate for Payer: HUMANA Commercial |
$112.50
|
| Rate for Payer: MEDICAID Medicaid |
$115.00
|
| Rate for Payer: MEDICARE Medicare |
$87.50
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$118.75
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$121.25
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$118.75
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$118.75
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$106.25
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$100.00
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$100.00
|
|
|
RUBELLA AB, IGG (006197)
|
Facility
IP
|
$20.00
|
|
|
Service Code
|
CPT 86762
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
302
|
| 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 CLOSED PLAN NETWORK |
$19.00
|
| Rate for Payer: BCBS Healthlink |
$18.00
|
| Rate for Payer: BCBS HMK CHIP |
$18.00
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$18.00
|
| Rate for Payer: BCBS POS |
$19.00
|
| Rate for Payer: BCBS Traditional |
$20.00
|
| Rate for Payer: CASH_PRICE |
$16.00
|
| Rate for Payer: CIGNA Commercial |
$19.00
|
| Rate for Payer: CIGNA Medicare |
$18.00
|
| Rate for Payer: HUMANA Commercial |
$18.00
|
| Rate for Payer: MEDICAID Medicaid |
$18.40
|
| Rate for Payer: MEDICARE Medicare |
$14.00
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$19.00
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$19.40
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$19.00
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$19.00
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$17.00
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$16.00
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$16.00
|
|
|
RUBELLA AB, IGG (006197)
|
Facility
OP
|
$20.00
|
|
|
Service Code
|
CPT 86762
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
302
|
| 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 CLOSED PLAN NETWORK |
$19.00
|
| Rate for Payer: BCBS Healthlink |
$18.00
|
| Rate for Payer: BCBS HMK CHIP |
$18.00
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$18.00
|
| Rate for Payer: BCBS POS |
$19.00
|
| Rate for Payer: BCBS Traditional |
$20.00
|
| Rate for Payer: CASH_PRICE |
$16.00
|
| Rate for Payer: CIGNA Commercial |
$19.00
|
| Rate for Payer: CIGNA Medicare |
$18.00
|
| Rate for Payer: HUMANA Commercial |
$18.00
|
| Rate for Payer: MEDICAID Medicaid |
$18.40
|
| Rate for Payer: MEDICARE Medicare |
$14.00
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$19.00
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$19.40
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$19.00
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$19.00
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$17.00
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$16.00
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$16.00
|
|
|
SACRO-LUMBAR SUPPORT
|
Facility
IP
|
$120.00
|
|
|
Service Code
|
CPT L0625
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$84.00 |
| Max. Negotiated Rate |
$120.00 |
| Rate for Payer: AETNA Commercial |
$114.00
|
| Rate for Payer: AETNA Medicare |
$108.00
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$114.00
|
| Rate for Payer: BCBS Healthlink |
$108.00
|
| Rate for Payer: BCBS HMK CHIP |
$108.00
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$108.00
|
| Rate for Payer: BCBS POS |
$114.00
|
| Rate for Payer: BCBS Traditional |
$120.00
|
| Rate for Payer: CASH_PRICE |
$96.00
|
| Rate for Payer: CIGNA Commercial |
$114.00
|
| Rate for Payer: CIGNA Medicare |
$108.00
|
| Rate for Payer: HUMANA Commercial |
$108.00
|
| Rate for Payer: MEDICAID Medicaid |
$110.40
|
| Rate for Payer: MEDICARE Medicare |
$84.00
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$114.00
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$116.40
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$114.00
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$114.00
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$102.00
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$96.00
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$96.00
|
|
|
SACRO-LUMBAR SUPPORT
|
Facility
OP
|
$120.00
|
|
|
Service Code
|
CPT L0625
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$84.00 |
| Max. Negotiated Rate |
$120.00 |
| Rate for Payer: AETNA Commercial |
$114.00
|
| Rate for Payer: AETNA Medicare |
$108.00
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$114.00
|
| Rate for Payer: BCBS Healthlink |
$108.00
|
| Rate for Payer: BCBS HMK CHIP |
$108.00
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$108.00
|
| Rate for Payer: BCBS POS |
$114.00
|
| Rate for Payer: BCBS Traditional |
$120.00
|
| Rate for Payer: CASH_PRICE |
$96.00
|
| Rate for Payer: CIGNA Commercial |
$114.00
|
| Rate for Payer: CIGNA Medicare |
$108.00
|
| Rate for Payer: HUMANA Commercial |
$108.00
|
| Rate for Payer: MEDICAID Medicaid |
$110.40
|
| Rate for Payer: MEDICARE Medicare |
$84.00
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$114.00
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$116.40
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$114.00
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$114.00
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$102.00
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$96.00
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$96.00
|
|
|
SALICYLATE
|
Facility
OP
|
$174.00
|
|
|
Service Code
|
CPT 80179
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$121.80 |
| Max. Negotiated Rate |
$174.00 |
| Rate for Payer: AETNA Commercial |
$165.30
|
| Rate for Payer: AETNA Medicare |
$156.60
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$165.30
|
| Rate for Payer: BCBS Healthlink |
$156.60
|
| Rate for Payer: BCBS HMK CHIP |
$156.60
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$156.60
|
| Rate for Payer: BCBS POS |
$165.30
|
| Rate for Payer: BCBS Traditional |
$174.00
|
| Rate for Payer: CASH_PRICE |
$139.20
|
| Rate for Payer: CIGNA Commercial |
$165.30
|
| Rate for Payer: CIGNA Medicare |
$156.60
|
| Rate for Payer: HUMANA Commercial |
$156.60
|
| Rate for Payer: MEDICAID Medicaid |
$160.08
|
| Rate for Payer: MEDICARE Medicare |
$121.80
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$165.30
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$168.78
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$165.30
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$165.30
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$147.90
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$139.20
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$139.20
|
|
|
SALICYLATE
|
Facility
IP
|
$174.00
|
|
|
Service Code
|
CPT 80179
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$121.80 |
| Max. Negotiated Rate |
$174.00 |
| Rate for Payer: AETNA Commercial |
$165.30
|
| Rate for Payer: AETNA Medicare |
$156.60
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$165.30
|
| Rate for Payer: BCBS Healthlink |
$156.60
|
| Rate for Payer: BCBS HMK CHIP |
$156.60
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$156.60
|
| Rate for Payer: BCBS POS |
$165.30
|
| Rate for Payer: BCBS Traditional |
$174.00
|
| Rate for Payer: CASH_PRICE |
$139.20
|
| Rate for Payer: CIGNA Commercial |
$165.30
|
| Rate for Payer: CIGNA Medicare |
$156.60
|
| Rate for Payer: HUMANA Commercial |
$156.60
|
| Rate for Payer: MEDICAID Medicaid |
$160.08
|
| Rate for Payer: MEDICARE Medicare |
$121.80
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$165.30
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$168.78
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$165.30
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$165.30
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$147.90
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$139.20
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$139.20
|
|
|
SAM PELVIC SLING LG
|
Facility
OP
|
$261.00
|
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$182.70 |
| Max. Negotiated Rate |
$261.00 |
| Rate for Payer: AETNA Commercial |
$247.95
|
| Rate for Payer: AETNA Medicare |
$234.90
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$247.95
|
| Rate for Payer: BCBS Healthlink |
$234.90
|
| Rate for Payer: BCBS HMK CHIP |
$234.90
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$234.90
|
| Rate for Payer: BCBS POS |
$247.95
|
| Rate for Payer: BCBS Traditional |
$261.00
|
| Rate for Payer: CASH_PRICE |
$208.80
|
| Rate for Payer: CIGNA Commercial |
$247.95
|
| Rate for Payer: CIGNA Medicare |
$234.90
|
| Rate for Payer: HUMANA Commercial |
$234.90
|
| Rate for Payer: MEDICAID Medicaid |
$240.12
|
| Rate for Payer: MEDICARE Medicare |
$182.70
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$247.95
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$253.17
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$247.95
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$247.95
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$221.85
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$208.80
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$208.80
|
|
|
SAM PELVIC SLING LG
|
Facility
IP
|
$261.00
|
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$182.70 |
| Max. Negotiated Rate |
$261.00 |
| Rate for Payer: AETNA Commercial |
$247.95
|
| Rate for Payer: AETNA Medicare |
$234.90
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$247.95
|
| Rate for Payer: BCBS Healthlink |
$234.90
|
| Rate for Payer: BCBS HMK CHIP |
$234.90
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$234.90
|
| Rate for Payer: BCBS POS |
$247.95
|
| Rate for Payer: BCBS Traditional |
$261.00
|
| Rate for Payer: CASH_PRICE |
$208.80
|
| Rate for Payer: CIGNA Commercial |
$247.95
|
| Rate for Payer: CIGNA Medicare |
$234.90
|
| Rate for Payer: HUMANA Commercial |
$234.90
|
| Rate for Payer: MEDICAID Medicaid |
$240.12
|
| Rate for Payer: MEDICARE Medicare |
$182.70
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$247.95
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$253.17
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$247.95
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$247.95
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$221.85
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$208.80
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$208.80
|
|
|
SAM PELVIC SLING MD
|
Facility
IP
|
$261.00
|
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$182.70 |
| Max. Negotiated Rate |
$261.00 |
| Rate for Payer: AETNA Commercial |
$247.95
|
| Rate for Payer: AETNA Medicare |
$234.90
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$247.95
|
| Rate for Payer: BCBS Healthlink |
$234.90
|
| Rate for Payer: BCBS HMK CHIP |
$234.90
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$234.90
|
| Rate for Payer: BCBS POS |
$247.95
|
| Rate for Payer: BCBS Traditional |
$261.00
|
| Rate for Payer: CASH_PRICE |
$208.80
|
| Rate for Payer: CIGNA Commercial |
$247.95
|
| Rate for Payer: CIGNA Medicare |
$234.90
|
| Rate for Payer: HUMANA Commercial |
$234.90
|
| Rate for Payer: MEDICAID Medicaid |
$240.12
|
| Rate for Payer: MEDICARE Medicare |
$182.70
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$247.95
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$253.17
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$247.95
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$247.95
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$221.85
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$208.80
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$208.80
|
|
|
SAM PELVIC SLING MD
|
Facility
OP
|
$261.00
|
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$182.70 |
| Max. Negotiated Rate |
$261.00 |
| Rate for Payer: AETNA Commercial |
$247.95
|
| Rate for Payer: AETNA Medicare |
$234.90
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$247.95
|
| Rate for Payer: BCBS Healthlink |
$234.90
|
| Rate for Payer: BCBS HMK CHIP |
$234.90
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$234.90
|
| Rate for Payer: BCBS POS |
$247.95
|
| Rate for Payer: BCBS Traditional |
$261.00
|
| Rate for Payer: CASH_PRICE |
$208.80
|
| Rate for Payer: CIGNA Commercial |
$247.95
|
| Rate for Payer: CIGNA Medicare |
$234.90
|
| Rate for Payer: HUMANA Commercial |
$234.90
|
| Rate for Payer: MEDICAID Medicaid |
$240.12
|
| Rate for Payer: MEDICARE Medicare |
$182.70
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$247.95
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$253.17
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$247.95
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$247.95
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$221.85
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$208.80
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$208.80
|
|
|
SAM PELVIC SLING SM
|
Facility
IP
|
$305.00
|
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$213.50 |
| Max. Negotiated Rate |
$305.00 |
| Rate for Payer: AETNA Commercial |
$289.75
|
| Rate for Payer: AETNA Medicare |
$274.50
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$289.75
|
| Rate for Payer: BCBS Healthlink |
$274.50
|
| Rate for Payer: BCBS HMK CHIP |
$274.50
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$274.50
|
| Rate for Payer: BCBS POS |
$289.75
|
| Rate for Payer: BCBS Traditional |
$305.00
|
| Rate for Payer: CASH_PRICE |
$244.00
|
| Rate for Payer: CIGNA Commercial |
$289.75
|
| Rate for Payer: CIGNA Medicare |
$274.50
|
| Rate for Payer: HUMANA Commercial |
$274.50
|
| Rate for Payer: MEDICAID Medicaid |
$280.60
|
| Rate for Payer: MEDICARE Medicare |
$213.50
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$289.75
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$295.85
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$289.75
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$289.75
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$259.25
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$244.00
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$244.00
|
|
|
SAM PELVIC SLING SM
|
Facility
OP
|
$305.00
|
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$213.50 |
| Max. Negotiated Rate |
$305.00 |
| Rate for Payer: AETNA Commercial |
$289.75
|
| Rate for Payer: AETNA Medicare |
$274.50
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$289.75
|
| Rate for Payer: BCBS Healthlink |
$274.50
|
| Rate for Payer: BCBS HMK CHIP |
$274.50
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$274.50
|
| Rate for Payer: BCBS POS |
$289.75
|
| Rate for Payer: BCBS Traditional |
$305.00
|
| Rate for Payer: CASH_PRICE |
$244.00
|
| Rate for Payer: CIGNA Commercial |
$289.75
|
| Rate for Payer: CIGNA Medicare |
$274.50
|
| Rate for Payer: HUMANA Commercial |
$274.50
|
| Rate for Payer: MEDICAID Medicaid |
$280.60
|
| Rate for Payer: MEDICARE Medicare |
$213.50
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$289.75
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$295.85
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$289.75
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$289.75
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$259.25
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$244.00
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$244.00
|
|
|
SAM SPLINT 4 1/4"X36''
|
Facility
OP
|
$43.00
|
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$30.10 |
| Max. Negotiated Rate |
$43.00 |
| Rate for Payer: AETNA Commercial |
$40.85
|
| Rate for Payer: AETNA Medicare |
$38.70
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$40.85
|
| Rate for Payer: BCBS Healthlink |
$38.70
|
| Rate for Payer: BCBS HMK CHIP |
$38.70
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$38.70
|
| Rate for Payer: BCBS POS |
$40.85
|
| Rate for Payer: BCBS Traditional |
$43.00
|
| Rate for Payer: CASH_PRICE |
$34.40
|
| Rate for Payer: CIGNA Commercial |
$40.85
|
| Rate for Payer: CIGNA Medicare |
$38.70
|
| Rate for Payer: HUMANA Commercial |
$38.70
|
| Rate for Payer: MEDICAID Medicaid |
$39.56
|
| Rate for Payer: MEDICARE Medicare |
$30.10
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$40.85
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$41.71
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$40.85
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$40.85
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$36.55
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$34.40
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$34.40
|
|
|
SAM SPLINT 4 1/4"X36''
|
Facility
IP
|
$43.00
|
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$30.10 |
| Max. Negotiated Rate |
$43.00 |
| Rate for Payer: AETNA Commercial |
$40.85
|
| Rate for Payer: AETNA Medicare |
$38.70
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$40.85
|
| Rate for Payer: BCBS Healthlink |
$38.70
|
| Rate for Payer: BCBS HMK CHIP |
$38.70
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$38.70
|
| Rate for Payer: BCBS POS |
$40.85
|
| Rate for Payer: BCBS Traditional |
$43.00
|
| Rate for Payer: CASH_PRICE |
$34.40
|
| Rate for Payer: CIGNA Commercial |
$40.85
|
| Rate for Payer: CIGNA Medicare |
$38.70
|
| Rate for Payer: HUMANA Commercial |
$38.70
|
| Rate for Payer: MEDICAID Medicaid |
$39.56
|
| Rate for Payer: MEDICARE Medicare |
$30.10
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$40.85
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$41.71
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$40.85
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$40.85
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$36.55
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$34.40
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$34.40
|
|
|
SAM SPLINT 4.25"X36" FLAT
|
Facility
OP
|
$43.00
|
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$30.10 |
| Max. Negotiated Rate |
$43.00 |
| Rate for Payer: AETNA Commercial |
$40.85
|
| Rate for Payer: AETNA Medicare |
$38.70
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$40.85
|
| Rate for Payer: BCBS Healthlink |
$38.70
|
| Rate for Payer: BCBS HMK CHIP |
$38.70
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$38.70
|
| Rate for Payer: BCBS POS |
$40.85
|
| Rate for Payer: BCBS Traditional |
$43.00
|
| Rate for Payer: CASH_PRICE |
$34.40
|
| Rate for Payer: CIGNA Commercial |
$40.85
|
| Rate for Payer: CIGNA Medicare |
$38.70
|
| Rate for Payer: HUMANA Commercial |
$38.70
|
| Rate for Payer: MEDICAID Medicaid |
$39.56
|
| Rate for Payer: MEDICARE Medicare |
$30.10
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$40.85
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$41.71
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$40.85
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$40.85
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$36.55
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$34.40
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$34.40
|
|
|
SAM SPLINT 4.25"X36" FLAT
|
Facility
IP
|
$43.00
|
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$30.10 |
| Max. Negotiated Rate |
$43.00 |
| Rate for Payer: AETNA Commercial |
$40.85
|
| Rate for Payer: AETNA Medicare |
$38.70
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$40.85
|
| Rate for Payer: BCBS Healthlink |
$38.70
|
| Rate for Payer: BCBS HMK CHIP |
$38.70
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$38.70
|
| Rate for Payer: BCBS POS |
$40.85
|
| Rate for Payer: BCBS Traditional |
$43.00
|
| Rate for Payer: CASH_PRICE |
$34.40
|
| Rate for Payer: CIGNA Commercial |
$40.85
|
| Rate for Payer: CIGNA Medicare |
$38.70
|
| Rate for Payer: HUMANA Commercial |
$38.70
|
| Rate for Payer: MEDICAID Medicaid |
$39.56
|
| Rate for Payer: MEDICARE Medicare |
$30.10
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$40.85
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$41.71
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$40.85
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$40.85
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$36.55
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$34.40
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$34.40
|
|
|
SARS-COV-2/FLU A/FLU B/RSV, RT-PCR
|
Facility
OP
|
$521.00
|
|
|
Service Code
|
CPT 0241U
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$364.70 |
| Max. Negotiated Rate |
$521.00 |
| Rate for Payer: AETNA Commercial |
$494.95
|
| Rate for Payer: AETNA Medicare |
$468.90
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$494.95
|
| Rate for Payer: BCBS Healthlink |
$468.90
|
| Rate for Payer: BCBS HMK CHIP |
$468.90
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$468.90
|
| Rate for Payer: BCBS POS |
$494.95
|
| Rate for Payer: BCBS Traditional |
$521.00
|
| Rate for Payer: CASH_PRICE |
$416.80
|
| Rate for Payer: CIGNA Commercial |
$494.95
|
| Rate for Payer: CIGNA Medicare |
$468.90
|
| Rate for Payer: HUMANA Commercial |
$468.90
|
| Rate for Payer: MEDICAID Medicaid |
$479.32
|
| Rate for Payer: MEDICARE Medicare |
$364.70
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$494.95
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$505.37
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$494.95
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$494.95
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$442.85
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$416.80
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$416.80
|
|
|
SARS-COV-2/FLU A/FLU B/RSV, RT-PCR
|
Facility
IP
|
$521.00
|
|
|
Service Code
|
CPT 0241U
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$364.70 |
| Max. Negotiated Rate |
$521.00 |
| Rate for Payer: AETNA Commercial |
$494.95
|
| Rate for Payer: AETNA Medicare |
$468.90
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$494.95
|
| Rate for Payer: BCBS Healthlink |
$468.90
|
| Rate for Payer: BCBS HMK CHIP |
$468.90
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$468.90
|
| Rate for Payer: BCBS POS |
$494.95
|
| Rate for Payer: BCBS Traditional |
$521.00
|
| Rate for Payer: CASH_PRICE |
$416.80
|
| Rate for Payer: CIGNA Commercial |
$494.95
|
| Rate for Payer: CIGNA Medicare |
$468.90
|
| Rate for Payer: HUMANA Commercial |
$468.90
|
| Rate for Payer: MEDICAID Medicaid |
$479.32
|
| Rate for Payer: MEDICARE Medicare |
$364.70
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$494.95
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$505.37
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$494.95
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$494.95
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$442.85
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$416.80
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$416.80
|
|
