|
CIPROFLOXACIN PREMIX [400 MG/200 ML]
|
Facility
IP
|
$14.00
|
|
|
Service Code
|
CPT J0706
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$9.80 |
| Max. Negotiated Rate |
$14.00 |
| Rate for Payer: AETNA Commercial |
$13.30
|
| Rate for Payer: AETNA Medicare |
$12.60
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$13.30
|
| Rate for Payer: BCBS Healthlink |
$12.60
|
| Rate for Payer: BCBS HMK CHIP |
$12.60
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$12.60
|
| Rate for Payer: BCBS POS |
$13.30
|
| Rate for Payer: BCBS Traditional |
$14.00
|
| Rate for Payer: CASH_PRICE |
$11.20
|
| Rate for Payer: CIGNA Commercial |
$13.30
|
| Rate for Payer: CIGNA Medicare |
$12.60
|
| Rate for Payer: HUMANA Commercial |
$12.60
|
| Rate for Payer: MEDICAID Medicaid |
$12.88
|
| Rate for Payer: MEDICARE Medicare |
$9.80
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$13.30
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$13.58
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$13.30
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$13.30
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$11.90
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$11.20
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$11.20
|
|
|
CIPROFLOXACIN PREMIX [400 MG/200 ML]
|
Facility
OP
|
$14.00
|
|
|
Service Code
|
CPT J0706
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$9.80 |
| Max. Negotiated Rate |
$14.00 |
| Rate for Payer: AETNA Commercial |
$13.30
|
| Rate for Payer: AETNA Medicare |
$12.60
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$13.30
|
| Rate for Payer: BCBS Healthlink |
$12.60
|
| Rate for Payer: BCBS HMK CHIP |
$12.60
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$12.60
|
| Rate for Payer: BCBS POS |
$13.30
|
| Rate for Payer: BCBS Traditional |
$14.00
|
| Rate for Payer: CASH_PRICE |
$11.20
|
| Rate for Payer: CIGNA Commercial |
$13.30
|
| Rate for Payer: CIGNA Medicare |
$12.60
|
| Rate for Payer: HUMANA Commercial |
$12.60
|
| Rate for Payer: MEDICAID Medicaid |
$12.88
|
| Rate for Payer: MEDICARE Medicare |
$9.80
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$13.30
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$13.58
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$13.30
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$13.30
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$11.90
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$11.20
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$11.20
|
|
|
CIPROFLOXACIN TAB [250 MG]
|
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: BCBS HMK CHIP |
$13.50
|
| 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 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
|
|
|
CIPROFLOXACIN TAB [250 MG]
|
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
|
|
|
CIPROFLOXACIN TAB [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
|
|
|
CIPROFLOXACIN TAB [500 MG]
|
Facility
IP
|
$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
|
|
|
CITALOPRAM TAB [20 MG]
|
Facility
OP
|
$9.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
250
|
| 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
|
|
|
CITALOPRAM TAB [20 MG]
|
Facility
IP
|
$9.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.30 |
| Max. Negotiated Rate |
$9.00 |
| Rate for Payer: BCBS HMK CHIP |
$8.10
|
| 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 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
|
|
|
CKMB (120816)
|
Facility
OP
|
$200.00
|
|
|
Service Code
|
CPT 82553
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$140.00 |
| Max. Negotiated Rate |
$200.00 |
| Rate for Payer: AETNA Commercial |
$190.00
|
| Rate for Payer: AETNA Medicare |
$180.00
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$190.00
|
| Rate for Payer: BCBS Healthlink |
$180.00
|
| Rate for Payer: BCBS HMK CHIP |
$180.00
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$180.00
|
| Rate for Payer: BCBS POS |
$190.00
|
| Rate for Payer: BCBS Traditional |
$200.00
|
| Rate for Payer: CASH_PRICE |
$160.00
|
| Rate for Payer: CIGNA Commercial |
$190.00
|
| Rate for Payer: CIGNA Medicare |
$180.00
|
| Rate for Payer: HUMANA Commercial |
$180.00
|
| Rate for Payer: MEDICAID Medicaid |
$184.00
|
| Rate for Payer: MEDICARE Medicare |
$140.00
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$190.00
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$194.00
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$190.00
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$190.00
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$170.00
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$160.00
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$160.00
|
|
|
CKMB (120816)
|
Facility
IP
|
$200.00
|
|
|
Service Code
|
CPT 82553
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$140.00 |
| Max. Negotiated Rate |
$200.00 |
| Rate for Payer: AETNA Commercial |
$190.00
|
| Rate for Payer: AETNA Medicare |
$180.00
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$190.00
|
| Rate for Payer: BCBS Healthlink |
$180.00
|
| Rate for Payer: BCBS HMK CHIP |
$180.00
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$180.00
|
| Rate for Payer: BCBS POS |
$190.00
|
| Rate for Payer: BCBS Traditional |
$200.00
|
| Rate for Payer: CASH_PRICE |
$160.00
|
| Rate for Payer: CIGNA Commercial |
$190.00
|
| Rate for Payer: CIGNA Medicare |
$180.00
|
| Rate for Payer: HUMANA Commercial |
$180.00
|
| Rate for Payer: MEDICAID Medicaid |
$184.00
|
| Rate for Payer: MEDICARE Medicare |
$140.00
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$190.00
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$194.00
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$190.00
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$190.00
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$170.00
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$160.00
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$160.00
|
|
|
CLARITHROMYCIN 500MG TAB NON FORMULARY
|
Facility
IP
|
$20.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$14.00 |
| Max. Negotiated Rate |
$20.00 |
| Rate for Payer: BCBS HMK CHIP |
$18.00
|
| 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 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
|
|
|
CLARITHROMYCIN 500MG TAB NON FORMULARY
|
Facility
OP
|
$20.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
250
|
| 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
|
|
|
CLAVICAL SPLINT LG
|
Facility
OP
|
$20.00
|
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
290
|
| 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
|
|
|
CLAVICAL SPLINT LG
|
Facility
IP
|
$20.00
|
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
290
|
| 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
|
|
|
CLAVICAL SPLINT MD
|
Facility
OP
|
$20.00
|
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
290
|
| 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
|
|
|
CLAVICAL SPLINT MD
|
Facility
IP
|
$20.00
|
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$14.00 |
| Max. Negotiated Rate |
$20.00 |
| Rate for Payer: BCBS HMK CHIP |
$18.00
|
| 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 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
|
|
|
CLAVICAL SPLINT SM
|
Facility
OP
|
$20.00
|
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
290
|
| 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
|
|
|
CLAVICAL SPLINT SM
|
Facility
IP
|
$20.00
|
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
290
|
| 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
|
|
|
CLAVICAL SPLINT XL
|
Facility
IP
|
$20.00
|
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$14.00 |
| Max. Negotiated Rate |
$20.00 |
| Rate for Payer: BCBS HMK CHIP |
$18.00
|
| 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 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
|
|
|
CLAVICAL SPLINT XL
|
Facility
OP
|
$20.00
|
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
290
|
| 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
|
|
|
CLAVICL SPLINT UNIVERSAL
|
Facility
OP
|
$38.00
|
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$26.60 |
| Max. Negotiated Rate |
$38.00 |
| Rate for Payer: AETNA Commercial |
$36.10
|
| Rate for Payer: AETNA Medicare |
$34.20
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$36.10
|
| Rate for Payer: BCBS Healthlink |
$34.20
|
| Rate for Payer: BCBS HMK CHIP |
$34.20
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$34.20
|
| Rate for Payer: BCBS POS |
$36.10
|
| Rate for Payer: BCBS Traditional |
$38.00
|
| Rate for Payer: CASH_PRICE |
$30.40
|
| Rate for Payer: CIGNA Commercial |
$36.10
|
| Rate for Payer: CIGNA Medicare |
$34.20
|
| Rate for Payer: HUMANA Commercial |
$34.20
|
| Rate for Payer: MEDICAID Medicaid |
$34.96
|
| Rate for Payer: MEDICARE Medicare |
$26.60
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$36.10
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$36.86
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$36.10
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$36.10
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$32.30
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$30.40
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$30.40
|
|
|
CLAVICL SPLINT UNIVERSAL
|
Facility
IP
|
$38.00
|
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$26.60 |
| Max. Negotiated Rate |
$38.00 |
| Rate for Payer: AETNA Commercial |
$36.10
|
| Rate for Payer: AETNA Medicare |
$34.20
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$36.10
|
| Rate for Payer: BCBS Healthlink |
$34.20
|
| Rate for Payer: BCBS HMK CHIP |
$34.20
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$34.20
|
| Rate for Payer: BCBS POS |
$36.10
|
| Rate for Payer: BCBS Traditional |
$38.00
|
| Rate for Payer: CASH_PRICE |
$30.40
|
| Rate for Payer: CIGNA Commercial |
$36.10
|
| Rate for Payer: CIGNA Medicare |
$34.20
|
| Rate for Payer: HUMANA Commercial |
$34.20
|
| Rate for Payer: MEDICAID Medicaid |
$34.96
|
| Rate for Payer: MEDICARE Medicare |
$26.60
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$36.10
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$36.86
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$36.10
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$36.10
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$32.30
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$30.40
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$30.40
|
|
|
CLEANSING FOAM ALOE VESTA
|
Facility
IP
|
$25.00
|
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$17.50 |
| Max. Negotiated Rate |
$25.00 |
| Rate for Payer: BCBS HMK CHIP |
$22.50
|
| Rate for Payer: AETNA Commercial |
$23.75
|
| Rate for Payer: AETNA Medicare |
$22.50
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$23.75
|
| Rate for Payer: BCBS Healthlink |
$22.50
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$22.50
|
| Rate for Payer: BCBS POS |
$23.75
|
| Rate for Payer: BCBS Traditional |
$25.00
|
| Rate for Payer: CASH_PRICE |
$20.00
|
| Rate for Payer: CIGNA Commercial |
$23.75
|
| Rate for Payer: CIGNA Medicare |
$22.50
|
| Rate for Payer: HUMANA Commercial |
$22.50
|
| Rate for Payer: MEDICAID Medicaid |
$23.00
|
| Rate for Payer: MEDICARE Medicare |
$17.50
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$23.75
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$24.25
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$23.75
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$23.75
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$21.25
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$20.00
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$20.00
|
|
|
CLEANSING FOAM ALOE VESTA
|
Facility
OP
|
$25.00
|
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$17.50 |
| Max. Negotiated Rate |
$25.00 |
| Rate for Payer: AETNA Commercial |
$23.75
|
| Rate for Payer: AETNA Medicare |
$22.50
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$23.75
|
| Rate for Payer: BCBS Healthlink |
$22.50
|
| Rate for Payer: BCBS HMK CHIP |
$22.50
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$22.50
|
| Rate for Payer: BCBS POS |
$23.75
|
| Rate for Payer: BCBS Traditional |
$25.00
|
| Rate for Payer: CASH_PRICE |
$20.00
|
| Rate for Payer: CIGNA Commercial |
$23.75
|
| Rate for Payer: CIGNA Medicare |
$22.50
|
| Rate for Payer: HUMANA Commercial |
$22.50
|
| Rate for Payer: MEDICAID Medicaid |
$23.00
|
| Rate for Payer: MEDICARE Medicare |
$17.50
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$23.75
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$24.25
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$23.75
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$23.75
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$21.25
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$20.00
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$20.00
|
|
|
CLIN ACETAMINOPHEN ELIX [160 MG/5 ML]
|
Facility
OP
|
$5.00
|
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$3.50 |
| Max. Negotiated Rate |
$5.00 |
| Rate for Payer: AETNA Commercial |
$4.75
|
| Rate for Payer: AETNA Medicare |
$4.50
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$4.75
|
| Rate for Payer: BCBS Healthlink |
$4.50
|
| Rate for Payer: BCBS HMK CHIP |
$4.50
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$4.50
|
| Rate for Payer: BCBS POS |
$4.75
|
| Rate for Payer: BCBS Traditional |
$5.00
|
| Rate for Payer: CASH_PRICE |
$4.00
|
| Rate for Payer: CIGNA Commercial |
$4.75
|
| Rate for Payer: CIGNA Medicare |
$4.50
|
| Rate for Payer: HUMANA Commercial |
$4.50
|
| Rate for Payer: MEDICAID Medicaid |
$4.60
|
| Rate for Payer: MEDICARE Medicare |
$3.50
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$4.75
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$4.85
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$4.75
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$4.75
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$4.25
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$4.00
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$4.00
|
|
