|
DULOXETINE ER 60MG CAPS (CYMBALTA)
|
Facility
OP
|
$26.00
|
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$18.20 |
| Max. Negotiated Rate |
$26.00 |
| Rate for Payer: AETNA Commercial |
$24.70
|
| Rate for Payer: AETNA Medicare |
$23.40
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$24.70
|
| Rate for Payer: BCBS Healthlink |
$23.40
|
| Rate for Payer: BCBS HMK CHIP |
$23.40
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$23.40
|
| Rate for Payer: BCBS POS |
$24.70
|
| Rate for Payer: BCBS Traditional |
$26.00
|
| Rate for Payer: CASH_PRICE |
$20.80
|
| Rate for Payer: CIGNA Commercial |
$24.70
|
| Rate for Payer: CIGNA Medicare |
$23.40
|
| Rate for Payer: HUMANA Commercial |
$23.40
|
| Rate for Payer: MEDICAID Medicaid |
$23.92
|
| Rate for Payer: MEDICARE Medicare |
$18.20
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$24.70
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$25.22
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$24.70
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$24.70
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$22.10
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$20.80
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$20.80
|
|
|
DUODERM 4X4
|
Facility
IP
|
$45.00
|
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$31.50 |
| Max. Negotiated Rate |
$45.00 |
| Rate for Payer: BCBS HMK CHIP |
$40.50
|
| Rate for Payer: AETNA Commercial |
$42.75
|
| Rate for Payer: AETNA Medicare |
$40.50
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$42.75
|
| Rate for Payer: BCBS Healthlink |
$40.50
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$40.50
|
| Rate for Payer: BCBS POS |
$42.75
|
| Rate for Payer: BCBS Traditional |
$45.00
|
| Rate for Payer: CASH_PRICE |
$36.00
|
| Rate for Payer: CIGNA Commercial |
$42.75
|
| Rate for Payer: CIGNA Medicare |
$40.50
|
| Rate for Payer: HUMANA Commercial |
$40.50
|
| Rate for Payer: MEDICAID Medicaid |
$41.40
|
| Rate for Payer: MEDICARE Medicare |
$31.50
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$42.75
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$43.65
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$42.75
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$42.75
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$38.25
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$36.00
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$36.00
|
|
|
DUODERM 4X4
|
Facility
OP
|
$45.00
|
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$31.50 |
| Max. Negotiated Rate |
$45.00 |
| Rate for Payer: AETNA Commercial |
$42.75
|
| Rate for Payer: AETNA Medicare |
$40.50
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$42.75
|
| Rate for Payer: BCBS Healthlink |
$40.50
|
| Rate for Payer: BCBS HMK CHIP |
$40.50
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$40.50
|
| Rate for Payer: BCBS POS |
$42.75
|
| Rate for Payer: BCBS Traditional |
$45.00
|
| Rate for Payer: CASH_PRICE |
$36.00
|
| Rate for Payer: CIGNA Commercial |
$42.75
|
| Rate for Payer: CIGNA Medicare |
$40.50
|
| Rate for Payer: HUMANA Commercial |
$40.50
|
| Rate for Payer: MEDICAID Medicaid |
$41.40
|
| Rate for Payer: MEDICARE Medicare |
$31.50
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$42.75
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$43.65
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$42.75
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$42.75
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$38.25
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$36.00
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$36.00
|
|
|
DUODERM 6X8
|
Facility
OP
|
$135.00
|
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$94.50 |
| Max. Negotiated Rate |
$135.00 |
| Rate for Payer: AETNA Commercial |
$128.25
|
| Rate for Payer: AETNA Medicare |
$121.50
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$128.25
|
| Rate for Payer: BCBS Healthlink |
$121.50
|
| Rate for Payer: BCBS HMK CHIP |
$121.50
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$121.50
|
| Rate for Payer: BCBS POS |
$128.25
|
| Rate for Payer: BCBS Traditional |
$135.00
|
| Rate for Payer: CASH_PRICE |
$108.00
|
| Rate for Payer: CIGNA Commercial |
$128.25
|
| Rate for Payer: CIGNA Medicare |
$121.50
|
| Rate for Payer: HUMANA Commercial |
$121.50
|
| Rate for Payer: MEDICAID Medicaid |
$124.20
|
| Rate for Payer: MEDICARE Medicare |
$94.50
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$128.25
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$130.95
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$128.25
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$128.25
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$114.75
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$108.00
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$108.00
|
|
|
DUODERM 6X8
|
Facility
IP
|
$135.00
|
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$94.50 |
| Max. Negotiated Rate |
$135.00 |
| Rate for Payer: AETNA Commercial |
$128.25
|
| Rate for Payer: AETNA Medicare |
$121.50
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$128.25
|
| Rate for Payer: BCBS Healthlink |
$121.50
|
| Rate for Payer: BCBS HMK CHIP |
$121.50
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$121.50
|
| Rate for Payer: BCBS POS |
$128.25
|
| Rate for Payer: BCBS Traditional |
$135.00
|
| Rate for Payer: CASH_PRICE |
$108.00
|
| Rate for Payer: CIGNA Commercial |
$128.25
|
| Rate for Payer: CIGNA Medicare |
$121.50
|
| Rate for Payer: HUMANA Commercial |
$121.50
|
| Rate for Payer: MEDICAID Medicaid |
$124.20
|
| Rate for Payer: MEDICARE Medicare |
$94.50
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$128.25
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$130.95
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$128.25
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$128.25
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$114.75
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$108.00
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$108.00
|
|
|
EASYDROP FLOW CONTROLLER
|
Facility
IP
|
$64.00
|
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$44.80 |
| Max. Negotiated Rate |
$64.00 |
| Rate for Payer: BCBS HMK CHIP |
$57.60
|
| Rate for Payer: AETNA Commercial |
$60.80
|
| Rate for Payer: AETNA Medicare |
$57.60
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$60.80
|
| Rate for Payer: BCBS Healthlink |
$57.60
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$57.60
|
| Rate for Payer: BCBS POS |
$60.80
|
| Rate for Payer: BCBS Traditional |
$64.00
|
| Rate for Payer: CASH_PRICE |
$51.20
|
| Rate for Payer: CIGNA Commercial |
$60.80
|
| Rate for Payer: CIGNA Medicare |
$57.60
|
| Rate for Payer: HUMANA Commercial |
$57.60
|
| Rate for Payer: MEDICAID Medicaid |
$58.88
|
| Rate for Payer: MEDICARE Medicare |
$44.80
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$60.80
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$62.08
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$60.80
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$60.80
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$54.40
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$51.20
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$51.20
|
|
|
EASYDROP FLOW CONTROLLER
|
Facility
OP
|
$64.00
|
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$44.80 |
| Max. Negotiated Rate |
$64.00 |
| Rate for Payer: AETNA Commercial |
$60.80
|
| Rate for Payer: AETNA Medicare |
$57.60
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$60.80
|
| Rate for Payer: BCBS Healthlink |
$57.60
|
| Rate for Payer: BCBS HMK CHIP |
$57.60
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$57.60
|
| Rate for Payer: BCBS POS |
$60.80
|
| Rate for Payer: BCBS Traditional |
$64.00
|
| Rate for Payer: CASH_PRICE |
$51.20
|
| Rate for Payer: CIGNA Commercial |
$60.80
|
| Rate for Payer: CIGNA Medicare |
$57.60
|
| Rate for Payer: HUMANA Commercial |
$57.60
|
| Rate for Payer: MEDICAID Medicaid |
$58.88
|
| Rate for Payer: MEDICARE Medicare |
$44.80
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$60.80
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$62.08
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$60.80
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$60.80
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$54.40
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$51.20
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$51.20
|
|
|
EBV AB TO VCA, IGG (096230)
|
Facility
OP
|
$41.00
|
|
|
Service Code
|
CPT 86665
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
302
|
| 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
|
|
|
EBV AB TO VCA, IGG (096230)
|
Facility
IP
|
$41.00
|
|
|
Service Code
|
CPT 86665
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
302
|
| 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
|
|
|
EBV AB TO VCA, IGM (096735)
|
Facility
IP
|
$41.00
|
|
|
Service Code
|
CPT 86665
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$28.70 |
| Max. Negotiated Rate |
$41.00 |
| Rate for Payer: BCBS HMK CHIP |
$36.90
|
| 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 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
|
|
|
EBV AB TO VCA, IGM (096735)
|
Facility
OP
|
$41.00
|
|
|
Service Code
|
CPT 86665
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
302
|
| 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
|
|
|
EBV ANTIBODY PROFILE (240610)
|
Facility
IP
|
$124.00
|
|
|
Service Code
|
CPT 86664
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$86.80 |
| Max. Negotiated Rate |
$124.00 |
| Rate for Payer: AETNA Commercial |
$117.80
|
| Rate for Payer: AETNA Medicare |
$111.60
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$117.80
|
| Rate for Payer: BCBS Healthlink |
$111.60
|
| Rate for Payer: BCBS HMK CHIP |
$111.60
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$111.60
|
| Rate for Payer: BCBS POS |
$117.80
|
| Rate for Payer: BCBS Traditional |
$124.00
|
| Rate for Payer: CASH_PRICE |
$99.20
|
| Rate for Payer: CIGNA Commercial |
$117.80
|
| Rate for Payer: CIGNA Medicare |
$111.60
|
| Rate for Payer: HUMANA Commercial |
$111.60
|
| Rate for Payer: MEDICAID Medicaid |
$114.08
|
| Rate for Payer: MEDICARE Medicare |
$86.80
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$117.80
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$120.28
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$117.80
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$117.80
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$105.40
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$99.20
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$99.20
|
|
|
EBV ANTIBODY PROFILE (240610)
|
Facility
OP
|
$124.00
|
|
|
Service Code
|
CPT 86664
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$86.80 |
| Max. Negotiated Rate |
$124.00 |
| Rate for Payer: AETNA Commercial |
$117.80
|
| Rate for Payer: AETNA Medicare |
$111.60
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$117.80
|
| Rate for Payer: BCBS Healthlink |
$111.60
|
| Rate for Payer: BCBS HMK CHIP |
$111.60
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$111.60
|
| Rate for Payer: BCBS POS |
$117.80
|
| Rate for Payer: BCBS Traditional |
$124.00
|
| Rate for Payer: CASH_PRICE |
$99.20
|
| Rate for Payer: CIGNA Commercial |
$117.80
|
| Rate for Payer: CIGNA Medicare |
$111.60
|
| Rate for Payer: HUMANA Commercial |
$111.60
|
| Rate for Payer: MEDICAID Medicaid |
$114.08
|
| Rate for Payer: MEDICARE Medicare |
$86.80
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$117.80
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$120.28
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$117.80
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$117.80
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$105.40
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$99.20
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$99.20
|
|
|
EBV NUCLEAR ANTIGEN AB, IGG (010272)
|
Facility
IP
|
$42.00
|
|
|
Service Code
|
CPT 86664
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$29.40 |
| Max. Negotiated Rate |
$42.00 |
| Rate for Payer: BCBS HMK CHIP |
$37.80
|
| Rate for Payer: AETNA Commercial |
$39.90
|
| Rate for Payer: AETNA Medicare |
$37.80
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$39.90
|
| Rate for Payer: BCBS Healthlink |
$37.80
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$37.80
|
| Rate for Payer: BCBS POS |
$39.90
|
| Rate for Payer: BCBS Traditional |
$42.00
|
| Rate for Payer: CASH_PRICE |
$33.60
|
| Rate for Payer: CIGNA Commercial |
$39.90
|
| Rate for Payer: CIGNA Medicare |
$37.80
|
| Rate for Payer: HUMANA Commercial |
$37.80
|
| Rate for Payer: MEDICAID Medicaid |
$38.64
|
| Rate for Payer: MEDICARE Medicare |
$29.40
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$39.90
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$40.74
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$39.90
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$39.90
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$35.70
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$33.60
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$33.60
|
|
|
EBV NUCLEAR ANTIGEN AB, IGG (010272)
|
Facility
OP
|
$42.00
|
|
|
Service Code
|
CPT 86664
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$29.40 |
| Max. Negotiated Rate |
$42.00 |
| Rate for Payer: AETNA Commercial |
$39.90
|
| Rate for Payer: AETNA Medicare |
$37.80
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$39.90
|
| Rate for Payer: BCBS Healthlink |
$37.80
|
| Rate for Payer: BCBS HMK CHIP |
$37.80
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$37.80
|
| Rate for Payer: BCBS POS |
$39.90
|
| Rate for Payer: BCBS Traditional |
$42.00
|
| Rate for Payer: CASH_PRICE |
$33.60
|
| Rate for Payer: CIGNA Commercial |
$39.90
|
| Rate for Payer: CIGNA Medicare |
$37.80
|
| Rate for Payer: HUMANA Commercial |
$37.80
|
| Rate for Payer: MEDICAID Medicaid |
$38.64
|
| Rate for Payer: MEDICARE Medicare |
$29.40
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$39.90
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$40.74
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$39.90
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$39.90
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$35.70
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$33.60
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$33.60
|
|
|
EBV, QUALITATIVE, PCR (138289)
|
Facility
IP
|
$659.00
|
|
|
Service Code
|
CPT 87798
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$461.30 |
| Max. Negotiated Rate |
$659.00 |
| Rate for Payer: AETNA Commercial |
$626.05
|
| Rate for Payer: AETNA Medicare |
$593.10
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$626.05
|
| Rate for Payer: BCBS Healthlink |
$593.10
|
| Rate for Payer: BCBS HMK CHIP |
$593.10
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$593.10
|
| Rate for Payer: BCBS POS |
$626.05
|
| Rate for Payer: BCBS Traditional |
$659.00
|
| Rate for Payer: CASH_PRICE |
$527.20
|
| Rate for Payer: CIGNA Commercial |
$626.05
|
| Rate for Payer: CIGNA Medicare |
$593.10
|
| Rate for Payer: HUMANA Commercial |
$593.10
|
| Rate for Payer: MEDICAID Medicaid |
$606.28
|
| Rate for Payer: MEDICARE Medicare |
$461.30
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$626.05
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$639.23
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$626.05
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$626.05
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$560.15
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$527.20
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$527.20
|
|
|
EBV, QUALITATIVE, PCR (138289)
|
Facility
OP
|
$659.00
|
|
|
Service Code
|
CPT 87798
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$461.30 |
| Max. Negotiated Rate |
$659.00 |
| Rate for Payer: AETNA Commercial |
$626.05
|
| Rate for Payer: AETNA Medicare |
$593.10
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$626.05
|
| Rate for Payer: BCBS Healthlink |
$593.10
|
| Rate for Payer: BCBS HMK CHIP |
$593.10
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$593.10
|
| Rate for Payer: BCBS POS |
$626.05
|
| Rate for Payer: BCBS Traditional |
$659.00
|
| Rate for Payer: CASH_PRICE |
$527.20
|
| Rate for Payer: CIGNA Commercial |
$626.05
|
| Rate for Payer: CIGNA Medicare |
$593.10
|
| Rate for Payer: HUMANA Commercial |
$593.10
|
| Rate for Payer: MEDICAID Medicaid |
$606.28
|
| Rate for Payer: MEDICARE Medicare |
$461.30
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$626.05
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$639.23
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$626.05
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$626.05
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$560.15
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$527.20
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$527.20
|
|
|
EBV, QUANTITATIVE, PCR (138230)
|
Facility
IP
|
$630.00
|
|
|
Service Code
|
CPT 87799
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$441.00 |
| Max. Negotiated Rate |
$630.00 |
| Rate for Payer: BCBS HMK CHIP |
$567.00
|
| Rate for Payer: AETNA Commercial |
$598.50
|
| Rate for Payer: AETNA Medicare |
$567.00
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$598.50
|
| Rate for Payer: BCBS Healthlink |
$567.00
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$567.00
|
| Rate for Payer: BCBS POS |
$598.50
|
| Rate for Payer: BCBS Traditional |
$630.00
|
| Rate for Payer: CASH_PRICE |
$504.00
|
| Rate for Payer: CIGNA Commercial |
$598.50
|
| Rate for Payer: CIGNA Medicare |
$567.00
|
| Rate for Payer: HUMANA Commercial |
$567.00
|
| Rate for Payer: MEDICAID Medicaid |
$579.60
|
| Rate for Payer: MEDICARE Medicare |
$441.00
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$598.50
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$611.10
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$598.50
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$598.50
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$535.50
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$504.00
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$504.00
|
|
|
EBV, QUANTITATIVE, PCR (138230)
|
Facility
OP
|
$630.00
|
|
|
Service Code
|
CPT 87799
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$441.00 |
| Max. Negotiated Rate |
$630.00 |
| Rate for Payer: AETNA Commercial |
$598.50
|
| Rate for Payer: AETNA Medicare |
$567.00
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$598.50
|
| Rate for Payer: BCBS Healthlink |
$567.00
|
| Rate for Payer: BCBS HMK CHIP |
$567.00
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$567.00
|
| Rate for Payer: BCBS POS |
$598.50
|
| Rate for Payer: BCBS Traditional |
$630.00
|
| Rate for Payer: CASH_PRICE |
$504.00
|
| Rate for Payer: CIGNA Commercial |
$598.50
|
| Rate for Payer: CIGNA Medicare |
$567.00
|
| Rate for Payer: HUMANA Commercial |
$567.00
|
| Rate for Payer: MEDICAID Medicaid |
$579.60
|
| Rate for Payer: MEDICARE Medicare |
$441.00
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$598.50
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$611.10
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$598.50
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$598.50
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$535.50
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$504.00
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$504.00
|
|
|
ED MODERATE CONCIOUS SEDATION ADD ON 15M
|
Facility
OP
|
$127.00
|
|
|
Service Code
|
CPT 99153
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$88.90 |
| Max. Negotiated Rate |
$127.00 |
| Rate for Payer: AETNA Commercial |
$120.65
|
| Rate for Payer: AETNA Medicare |
$114.30
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$120.65
|
| Rate for Payer: BCBS Healthlink |
$114.30
|
| Rate for Payer: BCBS HMK CHIP |
$114.30
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$114.30
|
| Rate for Payer: BCBS POS |
$120.65
|
| Rate for Payer: BCBS Traditional |
$127.00
|
| Rate for Payer: CASH_PRICE |
$101.60
|
| Rate for Payer: CIGNA Commercial |
$120.65
|
| Rate for Payer: CIGNA Medicare |
$114.30
|
| Rate for Payer: HUMANA Commercial |
$114.30
|
| Rate for Payer: MEDICAID Medicaid |
$116.84
|
| Rate for Payer: MEDICARE Medicare |
$88.90
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$120.65
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$123.19
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$120.65
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$120.65
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$107.95
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$101.60
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$101.60
|
|
|
ED MODERATE CONCIOUS SEDATION ADD ON 15M
|
Facility
IP
|
$127.00
|
|
|
Service Code
|
CPT 99153
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$88.90 |
| Max. Negotiated Rate |
$127.00 |
| Rate for Payer: AETNA Commercial |
$120.65
|
| Rate for Payer: AETNA Medicare |
$114.30
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$120.65
|
| Rate for Payer: BCBS Healthlink |
$114.30
|
| Rate for Payer: BCBS HMK CHIP |
$114.30
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$114.30
|
| Rate for Payer: BCBS POS |
$120.65
|
| Rate for Payer: BCBS Traditional |
$127.00
|
| Rate for Payer: CASH_PRICE |
$101.60
|
| Rate for Payer: CIGNA Commercial |
$120.65
|
| Rate for Payer: CIGNA Medicare |
$114.30
|
| Rate for Payer: HUMANA Commercial |
$114.30
|
| Rate for Payer: MEDICAID Medicaid |
$116.84
|
| Rate for Payer: MEDICARE Medicare |
$88.90
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$120.65
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$123.19
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$120.65
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$120.65
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$107.95
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$101.60
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$101.60
|
|
|
EKG - AMBULANCE
|
Facility
OP
|
$179.00
|
|
|
Service Code
|
CPT 93005 QN
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
730
|
| Min. Negotiated Rate |
$125.30 |
| Max. Negotiated Rate |
$179.00 |
| Rate for Payer: AETNA Commercial |
$170.05
|
| Rate for Payer: AETNA Medicare |
$161.10
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$170.05
|
| Rate for Payer: BCBS Healthlink |
$161.10
|
| Rate for Payer: BCBS HMK CHIP |
$161.10
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$161.10
|
| Rate for Payer: BCBS POS |
$170.05
|
| Rate for Payer: BCBS Traditional |
$179.00
|
| Rate for Payer: CASH_PRICE |
$143.20
|
| Rate for Payer: CIGNA Commercial |
$170.05
|
| Rate for Payer: CIGNA Medicare |
$161.10
|
| Rate for Payer: HUMANA Commercial |
$161.10
|
| Rate for Payer: MEDICAID Medicaid |
$164.68
|
| Rate for Payer: MEDICARE Medicare |
$125.30
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$170.05
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$173.63
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$170.05
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$170.05
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$152.15
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$143.20
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$143.20
|
|
|
EKG - AMBULANCE
|
Facility
IP
|
$179.00
|
|
|
Service Code
|
CPT 93005 QN
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
730
|
| Min. Negotiated Rate |
$125.30 |
| Max. Negotiated Rate |
$179.00 |
| Rate for Payer: BCBS HMK CHIP |
$161.10
|
| Rate for Payer: AETNA Commercial |
$170.05
|
| Rate for Payer: AETNA Medicare |
$161.10
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$170.05
|
| Rate for Payer: BCBS Healthlink |
$161.10
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$161.10
|
| Rate for Payer: BCBS POS |
$170.05
|
| Rate for Payer: BCBS Traditional |
$179.00
|
| Rate for Payer: CASH_PRICE |
$143.20
|
| Rate for Payer: CIGNA Commercial |
$170.05
|
| Rate for Payer: CIGNA Medicare |
$161.10
|
| Rate for Payer: HUMANA Commercial |
$161.10
|
| Rate for Payer: MEDICAID Medicaid |
$164.68
|
| Rate for Payer: MEDICARE Medicare |
$125.30
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$170.05
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$173.63
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$170.05
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$170.05
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$152.15
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$143.20
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$143.20
|
|
|
EKG - CLINIC
|
Facility
IP
|
$186.00
|
|
|
Service Code
|
CPT 93000
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$130.20 |
| Max. Negotiated Rate |
$186.00 |
| Rate for Payer: AETNA Commercial |
$176.70
|
| Rate for Payer: AETNA Medicare |
$167.40
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$176.70
|
| Rate for Payer: BCBS Healthlink |
$167.40
|
| Rate for Payer: BCBS HMK CHIP |
$167.40
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$167.40
|
| Rate for Payer: BCBS POS |
$176.70
|
| Rate for Payer: BCBS Traditional |
$186.00
|
| Rate for Payer: CASH_PRICE |
$148.80
|
| Rate for Payer: CIGNA Commercial |
$176.70
|
| Rate for Payer: CIGNA Medicare |
$167.40
|
| Rate for Payer: HUMANA Commercial |
$167.40
|
| Rate for Payer: MEDICAID Medicaid |
$171.12
|
| Rate for Payer: MEDICARE Medicare |
$130.20
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$176.70
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$180.42
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$176.70
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$176.70
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$158.10
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$148.80
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$148.80
|
|
|
EKG - CLINIC
|
Facility
OP
|
$186.00
|
|
|
Service Code
|
CPT 93000
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$130.20 |
| Max. Negotiated Rate |
$186.00 |
| Rate for Payer: AETNA Commercial |
$176.70
|
| Rate for Payer: AETNA Medicare |
$167.40
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$176.70
|
| Rate for Payer: BCBS Healthlink |
$167.40
|
| Rate for Payer: BCBS HMK CHIP |
$167.40
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$167.40
|
| Rate for Payer: BCBS POS |
$176.70
|
| Rate for Payer: BCBS Traditional |
$186.00
|
| Rate for Payer: CASH_PRICE |
$148.80
|
| Rate for Payer: CIGNA Commercial |
$176.70
|
| Rate for Payer: CIGNA Medicare |
$167.40
|
| Rate for Payer: HUMANA Commercial |
$167.40
|
| Rate for Payer: MEDICAID Medicaid |
$171.12
|
| Rate for Payer: MEDICARE Medicare |
$130.20
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$176.70
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$180.42
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$176.70
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$176.70
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$158.10
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$148.80
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$148.80
|
|
