|
VISCOSITY, SERUM (004861)
|
Facility
IP
|
$41.00
|
|
|
Service Code
|
CPT 85810
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$28.70 |
| Max. Negotiated Rate |
$41.00 |
| Rate for Payer: AETNA Commercial |
$38.95
|
| Rate for Payer: AETNA Medicare |
$36.90
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$38.95
|
| Rate for Payer: BCBS Healthlink |
$36.90
|
| Rate for Payer: BCBS HMK CHIP |
$36.90
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$36.90
|
| Rate for Payer: BCBS POS |
$38.95
|
| Rate for Payer: BCBS Traditional |
$41.00
|
| Rate for Payer: CASH_PRICE |
$32.80
|
| Rate for Payer: CIGNA Commercial |
$38.95
|
| Rate for Payer: CIGNA Medicare |
$36.90
|
| Rate for Payer: HUMANA Commercial |
$36.90
|
| Rate for Payer: MEDICAID Medicaid |
$37.72
|
| Rate for Payer: MEDICARE Medicare |
$28.70
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$38.95
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$39.77
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$38.95
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$38.95
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$34.85
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$32.80
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$32.80
|
|
|
VISCOSITY, SERUM (004861)
|
Facility
OP
|
$41.00
|
|
|
Service Code
|
CPT 85810
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$28.70 |
| Max. Negotiated Rate |
$41.00 |
| Rate for Payer: AETNA Commercial |
$38.95
|
| Rate for Payer: AETNA Medicare |
$36.90
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$38.95
|
| Rate for Payer: BCBS Healthlink |
$36.90
|
| Rate for Payer: BCBS HMK CHIP |
$36.90
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$36.90
|
| Rate for Payer: BCBS POS |
$38.95
|
| Rate for Payer: BCBS Traditional |
$41.00
|
| Rate for Payer: CASH_PRICE |
$32.80
|
| Rate for Payer: CIGNA Commercial |
$38.95
|
| Rate for Payer: CIGNA Medicare |
$36.90
|
| Rate for Payer: HUMANA Commercial |
$36.90
|
| Rate for Payer: MEDICAID Medicaid |
$37.72
|
| Rate for Payer: MEDICARE Medicare |
$28.70
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$38.95
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$39.77
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$38.95
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$38.95
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$34.85
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$32.80
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$32.80
|
|
|
VITAMIN A (017509)
|
Facility
OP
|
$31.00
|
|
|
Service Code
|
CPT 84590
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$21.70 |
| Max. Negotiated Rate |
$31.00 |
| Rate for Payer: AETNA Commercial |
$29.45
|
| Rate for Payer: AETNA Medicare |
$27.90
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$29.45
|
| Rate for Payer: BCBS Healthlink |
$27.90
|
| Rate for Payer: BCBS HMK CHIP |
$27.90
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$27.90
|
| Rate for Payer: BCBS POS |
$29.45
|
| Rate for Payer: BCBS Traditional |
$31.00
|
| Rate for Payer: CASH_PRICE |
$24.80
|
| Rate for Payer: CIGNA Commercial |
$29.45
|
| Rate for Payer: CIGNA Medicare |
$27.90
|
| Rate for Payer: HUMANA Commercial |
$27.90
|
| Rate for Payer: MEDICAID Medicaid |
$28.52
|
| Rate for Payer: MEDICARE Medicare |
$21.70
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$29.45
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$30.07
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$29.45
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$29.45
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$26.35
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$24.80
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$24.80
|
|
|
VITAMIN A (017509)
|
Facility
IP
|
$31.00
|
|
|
Service Code
|
CPT 84590
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$21.70 |
| Max. Negotiated Rate |
$31.00 |
| Rate for Payer: AETNA Commercial |
$29.45
|
| Rate for Payer: AETNA Medicare |
$27.90
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$29.45
|
| Rate for Payer: BCBS Healthlink |
$27.90
|
| Rate for Payer: BCBS HMK CHIP |
$27.90
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$27.90
|
| Rate for Payer: BCBS POS |
$29.45
|
| Rate for Payer: BCBS Traditional |
$31.00
|
| Rate for Payer: CASH_PRICE |
$24.80
|
| Rate for Payer: CIGNA Commercial |
$29.45
|
| Rate for Payer: CIGNA Medicare |
$27.90
|
| Rate for Payer: HUMANA Commercial |
$27.90
|
| Rate for Payer: MEDICAID Medicaid |
$28.52
|
| Rate for Payer: MEDICARE Medicare |
$21.70
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$29.45
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$30.07
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$29.45
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$29.45
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$26.35
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$24.80
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$24.80
|
|
|
VITAMIN A & D TOPICAL
|
Facility
IP
|
$15.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.50 |
| Max. Negotiated Rate |
$15.00 |
| Rate for Payer: AETNA Commercial |
$14.25
|
| Rate for Payer: AETNA Medicare |
$13.50
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$14.25
|
| Rate for Payer: BCBS Healthlink |
$13.50
|
| Rate for Payer: BCBS HMK CHIP |
$13.50
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$13.50
|
| Rate for Payer: BCBS POS |
$14.25
|
| Rate for Payer: BCBS Traditional |
$15.00
|
| Rate for Payer: CASH_PRICE |
$12.00
|
| Rate for Payer: CIGNA Commercial |
$14.25
|
| Rate for Payer: CIGNA Medicare |
$13.50
|
| Rate for Payer: HUMANA Commercial |
$13.50
|
| Rate for Payer: MEDICAID Medicaid |
$13.80
|
| Rate for Payer: MEDICARE Medicare |
$10.50
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$14.25
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$14.55
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$14.25
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$14.25
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$12.75
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$12.00
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$12.00
|
|
|
VITAMIN A & D TOPICAL
|
Facility
OP
|
$15.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.50 |
| Max. Negotiated Rate |
$15.00 |
| Rate for Payer: AETNA Commercial |
$14.25
|
| Rate for Payer: AETNA Medicare |
$13.50
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$14.25
|
| Rate for Payer: BCBS Healthlink |
$13.50
|
| Rate for Payer: BCBS HMK CHIP |
$13.50
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$13.50
|
| Rate for Payer: BCBS POS |
$14.25
|
| Rate for Payer: BCBS Traditional |
$15.00
|
| Rate for Payer: CASH_PRICE |
$12.00
|
| Rate for Payer: CIGNA Commercial |
$14.25
|
| Rate for Payer: CIGNA Medicare |
$13.50
|
| Rate for Payer: HUMANA Commercial |
$13.50
|
| Rate for Payer: MEDICAID Medicaid |
$13.80
|
| Rate for Payer: MEDICARE Medicare |
$10.50
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$14.25
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$14.55
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$14.25
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$14.25
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$12.75
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$12.00
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$12.00
|
|
|
VITAMIN B12 (001503)
|
Facility
OP
|
$21.00
|
|
|
Service Code
|
CPT 82607
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$14.70 |
| Max. Negotiated Rate |
$21.00 |
| Rate for Payer: AETNA Commercial |
$19.95
|
| Rate for Payer: AETNA Medicare |
$18.90
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$19.95
|
| Rate for Payer: BCBS Healthlink |
$18.90
|
| Rate for Payer: BCBS HMK CHIP |
$18.90
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$18.90
|
| Rate for Payer: BCBS POS |
$19.95
|
| Rate for Payer: BCBS Traditional |
$21.00
|
| Rate for Payer: CASH_PRICE |
$16.80
|
| Rate for Payer: CIGNA Commercial |
$19.95
|
| Rate for Payer: CIGNA Medicare |
$18.90
|
| Rate for Payer: HUMANA Commercial |
$18.90
|
| Rate for Payer: MEDICAID Medicaid |
$19.32
|
| Rate for Payer: MEDICARE Medicare |
$14.70
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$19.95
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$20.37
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$19.95
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$19.95
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$17.85
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$16.80
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$16.80
|
|
|
VITAMIN B12 (001503)
|
Facility
IP
|
$21.00
|
|
|
Service Code
|
CPT 82607
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$14.70 |
| Max. Negotiated Rate |
$21.00 |
| Rate for Payer: AETNA Commercial |
$19.95
|
| Rate for Payer: AETNA Medicare |
$18.90
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$19.95
|
| Rate for Payer: BCBS Healthlink |
$18.90
|
| Rate for Payer: BCBS HMK CHIP |
$18.90
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$18.90
|
| Rate for Payer: BCBS POS |
$19.95
|
| Rate for Payer: BCBS Traditional |
$21.00
|
| Rate for Payer: CASH_PRICE |
$16.80
|
| Rate for Payer: CIGNA Commercial |
$19.95
|
| Rate for Payer: CIGNA Medicare |
$18.90
|
| Rate for Payer: HUMANA Commercial |
$18.90
|
| Rate for Payer: MEDICAID Medicaid |
$19.32
|
| Rate for Payer: MEDICARE Medicare |
$14.70
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$19.95
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$20.37
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$19.95
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$19.95
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$17.85
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$16.80
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$16.80
|
|
|
VITAMIN B12 100 MCG
|
Facility
IP
|
$8.00
|
|
| Hospital Charge Code |
20221105
|
|
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 CLOSED PLAN NETWORK |
$7.60
|
| Rate for Payer: BCBS Healthlink |
$7.20
|
| Rate for Payer: BCBS HMK CHIP |
$7.20
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$7.20
|
| Rate for Payer: BCBS POS |
$7.60
|
| Rate for Payer: BCBS Traditional |
$8.00
|
| Rate for Payer: CASH_PRICE |
$6.40
|
| Rate for Payer: CIGNA Commercial |
$7.60
|
| Rate for Payer: CIGNA Medicare |
$7.20
|
| Rate for Payer: HUMANA Commercial |
$7.20
|
| Rate for Payer: MEDICAID Medicaid |
$7.36
|
| Rate for Payer: MEDICARE Medicare |
$5.60
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$7.60
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$7.76
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$7.60
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$7.60
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$6.80
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$6.40
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$6.40
|
|
|
VITAMIN B12 100 MCG
|
Facility
OP
|
$8.00
|
|
| Hospital Charge Code |
20221105
|
|
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 CLOSED PLAN NETWORK |
$7.60
|
| Rate for Payer: BCBS Healthlink |
$7.20
|
| Rate for Payer: BCBS HMK CHIP |
$7.20
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$7.20
|
| Rate for Payer: BCBS POS |
$7.60
|
| Rate for Payer: BCBS Traditional |
$8.00
|
| Rate for Payer: CASH_PRICE |
$6.40
|
| Rate for Payer: CIGNA Commercial |
$7.60
|
| Rate for Payer: CIGNA Medicare |
$7.20
|
| Rate for Payer: HUMANA Commercial |
$7.20
|
| Rate for Payer: MEDICAID Medicaid |
$7.36
|
| Rate for Payer: MEDICARE Medicare |
$5.60
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$7.60
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$7.76
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$7.60
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$7.60
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$6.80
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$6.40
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$6.40
|
|
|
VITAMIN B12 500MCG TABLET
|
Facility
OP
|
$8.00
|
|
| Hospital Charge Code |
20221105
|
|
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 CLOSED PLAN NETWORK |
$7.60
|
| Rate for Payer: BCBS Healthlink |
$7.20
|
| Rate for Payer: BCBS HMK CHIP |
$7.20
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$7.20
|
| Rate for Payer: BCBS POS |
$7.60
|
| Rate for Payer: BCBS Traditional |
$8.00
|
| Rate for Payer: CASH_PRICE |
$6.40
|
| Rate for Payer: CIGNA Commercial |
$7.60
|
| Rate for Payer: CIGNA Medicare |
$7.20
|
| Rate for Payer: HUMANA Commercial |
$7.20
|
| Rate for Payer: MEDICAID Medicaid |
$7.36
|
| Rate for Payer: MEDICARE Medicare |
$5.60
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$7.60
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$7.76
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$7.60
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$7.60
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$6.80
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$6.40
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$6.40
|
|
|
VITAMIN B12 500MCG TABLET
|
Facility
IP
|
$8.00
|
|
| Hospital Charge Code |
20221105
|
|
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 CLOSED PLAN NETWORK |
$7.60
|
| Rate for Payer: BCBS Healthlink |
$7.20
|
| Rate for Payer: BCBS HMK CHIP |
$7.20
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$7.20
|
| Rate for Payer: BCBS POS |
$7.60
|
| Rate for Payer: BCBS Traditional |
$8.00
|
| Rate for Payer: CASH_PRICE |
$6.40
|
| Rate for Payer: CIGNA Commercial |
$7.60
|
| Rate for Payer: CIGNA Medicare |
$7.20
|
| Rate for Payer: HUMANA Commercial |
$7.20
|
| Rate for Payer: MEDICAID Medicaid |
$7.36
|
| Rate for Payer: MEDICARE Medicare |
$5.60
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$7.60
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$7.76
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$7.60
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$7.60
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$6.80
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$6.40
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$6.40
|
|
|
VITAMIN B12, REFLEX TO MMA (379196)
|
Facility
OP
|
$24.00
|
|
|
Service Code
|
CPT 82607
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
301
|
| 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 CLOSED PLAN NETWORK |
$22.80
|
| Rate for Payer: BCBS Healthlink |
$21.60
|
| Rate for Payer: BCBS HMK CHIP |
$21.60
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$21.60
|
| Rate for Payer: BCBS POS |
$22.80
|
| Rate for Payer: BCBS Traditional |
$24.00
|
| Rate for Payer: CASH_PRICE |
$19.20
|
| Rate for Payer: CIGNA Commercial |
$22.80
|
| Rate for Payer: CIGNA Medicare |
$21.60
|
| Rate for Payer: HUMANA Commercial |
$21.60
|
| Rate for Payer: MEDICAID Medicaid |
$22.08
|
| Rate for Payer: MEDICARE Medicare |
$16.80
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$22.80
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$23.28
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$22.80
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$22.80
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$20.40
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$19.20
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$19.20
|
|
|
VITAMIN B12, REFLEX TO MMA (379196)
|
Facility
IP
|
$24.00
|
|
|
Service Code
|
CPT 82607
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
301
|
| 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 CLOSED PLAN NETWORK |
$22.80
|
| Rate for Payer: BCBS Healthlink |
$21.60
|
| Rate for Payer: BCBS HMK CHIP |
$21.60
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$21.60
|
| Rate for Payer: BCBS POS |
$22.80
|
| Rate for Payer: BCBS Traditional |
$24.00
|
| Rate for Payer: CASH_PRICE |
$19.20
|
| Rate for Payer: CIGNA Commercial |
$22.80
|
| Rate for Payer: CIGNA Medicare |
$21.60
|
| Rate for Payer: HUMANA Commercial |
$21.60
|
| Rate for Payer: MEDICAID Medicaid |
$22.08
|
| Rate for Payer: MEDICARE Medicare |
$16.80
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$22.80
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$23.28
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$22.80
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$22.80
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$20.40
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$19.20
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$19.20
|
|
|
VITAMIN B-1 TAB 100 MG
|
Facility
IP
|
$8.00
|
|
| Hospital Charge Code |
20221105
|
|
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 CLOSED PLAN NETWORK |
$7.60
|
| Rate for Payer: BCBS Healthlink |
$7.20
|
| Rate for Payer: BCBS HMK CHIP |
$7.20
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$7.20
|
| Rate for Payer: BCBS POS |
$7.60
|
| Rate for Payer: BCBS Traditional |
$8.00
|
| Rate for Payer: CASH_PRICE |
$6.40
|
| Rate for Payer: CIGNA Commercial |
$7.60
|
| Rate for Payer: CIGNA Medicare |
$7.20
|
| Rate for Payer: HUMANA Commercial |
$7.20
|
| Rate for Payer: MEDICAID Medicaid |
$7.36
|
| Rate for Payer: MEDICARE Medicare |
$5.60
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$7.60
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$7.76
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$7.60
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$7.60
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$6.80
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$6.40
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$6.40
|
|
|
VITAMIN B-1 TAB 100 MG
|
Facility
OP
|
$8.00
|
|
| Hospital Charge Code |
20221105
|
|
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 CLOSED PLAN NETWORK |
$7.60
|
| Rate for Payer: BCBS Healthlink |
$7.20
|
| Rate for Payer: BCBS HMK CHIP |
$7.20
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$7.20
|
| Rate for Payer: BCBS POS |
$7.60
|
| Rate for Payer: BCBS Traditional |
$8.00
|
| Rate for Payer: CASH_PRICE |
$6.40
|
| Rate for Payer: CIGNA Commercial |
$7.60
|
| Rate for Payer: CIGNA Medicare |
$7.20
|
| Rate for Payer: HUMANA Commercial |
$7.20
|
| Rate for Payer: MEDICAID Medicaid |
$7.36
|
| Rate for Payer: MEDICARE Medicare |
$5.60
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$7.60
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$7.76
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$7.60
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$7.60
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$6.80
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$6.40
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$6.40
|
|
|
VITAMIN B2 (123220)
|
Facility
OP
|
$160.00
|
|
|
Service Code
|
CPT 84252
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$112.00 |
| Max. Negotiated Rate |
$160.00 |
| Rate for Payer: AETNA Commercial |
$152.00
|
| Rate for Payer: AETNA Medicare |
$144.00
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$152.00
|
| Rate for Payer: BCBS Healthlink |
$144.00
|
| Rate for Payer: BCBS HMK CHIP |
$144.00
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$144.00
|
| Rate for Payer: BCBS POS |
$152.00
|
| Rate for Payer: BCBS Traditional |
$160.00
|
| Rate for Payer: CASH_PRICE |
$128.00
|
| Rate for Payer: CIGNA Commercial |
$152.00
|
| Rate for Payer: CIGNA Medicare |
$144.00
|
| Rate for Payer: HUMANA Commercial |
$144.00
|
| Rate for Payer: MEDICAID Medicaid |
$147.20
|
| Rate for Payer: MEDICARE Medicare |
$112.00
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$152.00
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$155.20
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$152.00
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$152.00
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$136.00
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$128.00
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$128.00
|
|
|
VITAMIN B2 (123220)
|
Facility
IP
|
$160.00
|
|
|
Service Code
|
CPT 84252
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$112.00 |
| Max. Negotiated Rate |
$160.00 |
| Rate for Payer: AETNA Commercial |
$152.00
|
| Rate for Payer: AETNA Medicare |
$144.00
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$152.00
|
| Rate for Payer: BCBS Healthlink |
$144.00
|
| Rate for Payer: BCBS HMK CHIP |
$144.00
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$144.00
|
| Rate for Payer: BCBS POS |
$152.00
|
| Rate for Payer: BCBS Traditional |
$160.00
|
| Rate for Payer: CASH_PRICE |
$128.00
|
| Rate for Payer: CIGNA Commercial |
$152.00
|
| Rate for Payer: CIGNA Medicare |
$144.00
|
| Rate for Payer: HUMANA Commercial |
$144.00
|
| Rate for Payer: MEDICAID Medicaid |
$147.20
|
| Rate for Payer: MEDICARE Medicare |
$112.00
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$152.00
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$155.20
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$152.00
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$152.00
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$136.00
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$128.00
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$128.00
|
|
|
VITAMIN B3 (070115)
|
Facility
OP
|
$184.00
|
|
|
Service Code
|
CPT 84591
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$128.80 |
| Max. Negotiated Rate |
$184.00 |
| Rate for Payer: AETNA Commercial |
$174.80
|
| Rate for Payer: AETNA Medicare |
$165.60
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$174.80
|
| Rate for Payer: BCBS Healthlink |
$165.60
|
| Rate for Payer: BCBS HMK CHIP |
$165.60
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$165.60
|
| Rate for Payer: BCBS POS |
$174.80
|
| Rate for Payer: BCBS Traditional |
$184.00
|
| Rate for Payer: CASH_PRICE |
$147.20
|
| Rate for Payer: CIGNA Commercial |
$174.80
|
| Rate for Payer: CIGNA Medicare |
$165.60
|
| Rate for Payer: HUMANA Commercial |
$165.60
|
| Rate for Payer: MEDICAID Medicaid |
$169.28
|
| Rate for Payer: MEDICARE Medicare |
$128.80
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$174.80
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$178.48
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$174.80
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$174.80
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$156.40
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$147.20
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$147.20
|
|
|
VITAMIN B3 (070115)
|
Facility
IP
|
$184.00
|
|
|
Service Code
|
CPT 84591
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$128.80 |
| Max. Negotiated Rate |
$184.00 |
| Rate for Payer: AETNA Commercial |
$174.80
|
| Rate for Payer: AETNA Medicare |
$165.60
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$174.80
|
| Rate for Payer: BCBS Healthlink |
$165.60
|
| Rate for Payer: BCBS HMK CHIP |
$165.60
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$165.60
|
| Rate for Payer: BCBS POS |
$174.80
|
| Rate for Payer: BCBS Traditional |
$184.00
|
| Rate for Payer: CASH_PRICE |
$147.20
|
| Rate for Payer: CIGNA Commercial |
$174.80
|
| Rate for Payer: CIGNA Medicare |
$165.60
|
| Rate for Payer: HUMANA Commercial |
$165.60
|
| Rate for Payer: MEDICAID Medicaid |
$169.28
|
| Rate for Payer: MEDICARE Medicare |
$128.80
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$174.80
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$178.48
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$174.80
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$174.80
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$156.40
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$147.20
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$147.20
|
|
|
VITAMIN B6 (004655)
|
Facility
OP
|
$112.00
|
|
|
Service Code
|
CPT 84207
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$78.40 |
| Max. Negotiated Rate |
$112.00 |
| Rate for Payer: AETNA Commercial |
$106.40
|
| Rate for Payer: AETNA Medicare |
$100.80
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$106.40
|
| Rate for Payer: BCBS Healthlink |
$100.80
|
| Rate for Payer: BCBS HMK CHIP |
$100.80
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$100.80
|
| Rate for Payer: BCBS POS |
$106.40
|
| Rate for Payer: BCBS Traditional |
$112.00
|
| Rate for Payer: CASH_PRICE |
$89.60
|
| Rate for Payer: CIGNA Commercial |
$106.40
|
| Rate for Payer: CIGNA Medicare |
$100.80
|
| Rate for Payer: HUMANA Commercial |
$100.80
|
| Rate for Payer: MEDICAID Medicaid |
$103.04
|
| Rate for Payer: MEDICARE Medicare |
$78.40
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$106.40
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$108.64
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$106.40
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$106.40
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$95.20
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$89.60
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$89.60
|
|
|
VITAMIN B6 (004655)
|
Facility
IP
|
$112.00
|
|
|
Service Code
|
CPT 84207
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$78.40 |
| Max. Negotiated Rate |
$112.00 |
| Rate for Payer: AETNA Commercial |
$106.40
|
| Rate for Payer: AETNA Medicare |
$100.80
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$106.40
|
| Rate for Payer: BCBS Healthlink |
$100.80
|
| Rate for Payer: BCBS HMK CHIP |
$100.80
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$100.80
|
| Rate for Payer: BCBS POS |
$106.40
|
| Rate for Payer: BCBS Traditional |
$112.00
|
| Rate for Payer: CASH_PRICE |
$89.60
|
| Rate for Payer: CIGNA Commercial |
$106.40
|
| Rate for Payer: CIGNA Medicare |
$100.80
|
| Rate for Payer: HUMANA Commercial |
$100.80
|
| Rate for Payer: MEDICAID Medicaid |
$103.04
|
| Rate for Payer: MEDICARE Medicare |
$78.40
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$106.40
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$108.64
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$106.40
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$106.40
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$95.20
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$89.60
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$89.60
|
|
|
VITAMIN C (001805)
|
Facility
OP
|
$53.00
|
|
|
Service Code
|
CPT 82180
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$37.10 |
| Max. Negotiated Rate |
$53.00 |
| Rate for Payer: AETNA Commercial |
$50.35
|
| Rate for Payer: AETNA Medicare |
$47.70
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$50.35
|
| Rate for Payer: BCBS Healthlink |
$47.70
|
| Rate for Payer: BCBS HMK CHIP |
$47.70
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$47.70
|
| Rate for Payer: BCBS POS |
$50.35
|
| Rate for Payer: BCBS Traditional |
$53.00
|
| Rate for Payer: CASH_PRICE |
$42.40
|
| Rate for Payer: CIGNA Commercial |
$50.35
|
| Rate for Payer: CIGNA Medicare |
$47.70
|
| Rate for Payer: HUMANA Commercial |
$47.70
|
| Rate for Payer: MEDICAID Medicaid |
$48.76
|
| Rate for Payer: MEDICARE Medicare |
$37.10
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$50.35
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$51.41
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$50.35
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$50.35
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$45.05
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$42.40
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$42.40
|
|
|
VITAMIN C (001805)
|
Facility
IP
|
$53.00
|
|
|
Service Code
|
CPT 82180
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$37.10 |
| Max. Negotiated Rate |
$53.00 |
| Rate for Payer: AETNA Commercial |
$50.35
|
| Rate for Payer: AETNA Medicare |
$47.70
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$50.35
|
| Rate for Payer: BCBS Healthlink |
$47.70
|
| Rate for Payer: BCBS HMK CHIP |
$47.70
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$47.70
|
| Rate for Payer: BCBS POS |
$50.35
|
| Rate for Payer: BCBS Traditional |
$53.00
|
| Rate for Payer: CASH_PRICE |
$42.40
|
| Rate for Payer: CIGNA Commercial |
$50.35
|
| Rate for Payer: CIGNA Medicare |
$47.70
|
| Rate for Payer: HUMANA Commercial |
$47.70
|
| Rate for Payer: MEDICAID Medicaid |
$48.76
|
| Rate for Payer: MEDICARE Medicare |
$37.10
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$50.35
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$51.41
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$50.35
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$50.35
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$45.05
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$42.40
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$42.40
|
|
|
VITAMIN C [500 MG]
|
Facility
OP
|
$8.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
20221105
|
|
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 CLOSED PLAN NETWORK |
$7.60
|
| Rate for Payer: BCBS Healthlink |
$7.20
|
| Rate for Payer: BCBS HMK CHIP |
$7.20
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$7.20
|
| Rate for Payer: BCBS POS |
$7.60
|
| Rate for Payer: BCBS Traditional |
$8.00
|
| Rate for Payer: CASH_PRICE |
$6.40
|
| Rate for Payer: CIGNA Commercial |
$7.60
|
| Rate for Payer: CIGNA Medicare |
$7.20
|
| Rate for Payer: HUMANA Commercial |
$7.20
|
| Rate for Payer: MEDICAID Medicaid |
$7.36
|
| Rate for Payer: MEDICARE Medicare |
$5.60
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$7.60
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$7.76
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$7.60
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$7.60
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$6.80
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$6.40
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$6.40
|
|
