|
FILGRASTIM INJ [300 MCG/0.5 ML] SPEC ORD
|
Facility
OP
|
$754.00
|
|
|
Service Code
|
CPT J1442
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$527.80 |
| Max. Negotiated Rate |
$754.00 |
| Rate for Payer: AETNA Commercial |
$716.30
|
| Rate for Payer: AETNA Medicare |
$678.60
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$716.30
|
| Rate for Payer: BCBS Healthlink |
$678.60
|
| Rate for Payer: BCBS HMK CHIP |
$678.60
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$678.60
|
| Rate for Payer: BCBS POS |
$716.30
|
| Rate for Payer: BCBS Traditional |
$754.00
|
| Rate for Payer: CASH_PRICE |
$603.20
|
| Rate for Payer: CIGNA Commercial |
$716.30
|
| Rate for Payer: CIGNA Medicare |
$678.60
|
| Rate for Payer: HUMANA Commercial |
$678.60
|
| Rate for Payer: MEDICAID Medicaid |
$693.68
|
| Rate for Payer: MEDICARE Medicare |
$527.80
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$716.30
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$731.38
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$716.30
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$716.30
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$640.90
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$603.20
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$603.20
|
|
|
FINASTERIDE TAB [5 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: BCBS HMK CHIP |
$7.20
|
| 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 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
|
|
|
FINASTERIDE TAB [5 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
|
|
|
FINGER GUARDS ASST'D SIZES
|
Facility
IP
|
$20.00
|
|
|
Service Code
|
CPT A4570
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
270
|
| 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
|
|
|
FINGER GUARDS ASST'D SIZES
|
Facility
OP
|
$20.00
|
|
|
Service Code
|
CPT A4570
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
270
|
| 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
|
|
|
FINGER SPLINT SAM
|
Facility
OP
|
$89.00
|
|
|
Service Code
|
CPT A4570
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$62.30 |
| Max. Negotiated Rate |
$89.00 |
| Rate for Payer: AETNA Commercial |
$84.55
|
| Rate for Payer: AETNA Medicare |
$80.10
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$84.55
|
| Rate for Payer: BCBS Healthlink |
$80.10
|
| Rate for Payer: BCBS HMK CHIP |
$80.10
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$80.10
|
| Rate for Payer: BCBS POS |
$84.55
|
| Rate for Payer: BCBS Traditional |
$89.00
|
| Rate for Payer: CASH_PRICE |
$71.20
|
| Rate for Payer: CIGNA Commercial |
$84.55
|
| Rate for Payer: CIGNA Medicare |
$80.10
|
| Rate for Payer: HUMANA Commercial |
$80.10
|
| Rate for Payer: MEDICAID Medicaid |
$81.88
|
| Rate for Payer: MEDICARE Medicare |
$62.30
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$84.55
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$86.33
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$84.55
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$84.55
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$75.65
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$71.20
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$71.20
|
|
|
FINGER SPLINT SAM
|
Facility
IP
|
$89.00
|
|
|
Service Code
|
CPT A4570
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$62.30 |
| Max. Negotiated Rate |
$89.00 |
| Rate for Payer: BCBS HMK CHIP |
$80.10
|
| Rate for Payer: AETNA Commercial |
$84.55
|
| Rate for Payer: AETNA Medicare |
$80.10
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$84.55
|
| Rate for Payer: BCBS Healthlink |
$80.10
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$80.10
|
| Rate for Payer: BCBS POS |
$84.55
|
| Rate for Payer: BCBS Traditional |
$89.00
|
| Rate for Payer: CASH_PRICE |
$71.20
|
| Rate for Payer: CIGNA Commercial |
$84.55
|
| Rate for Payer: CIGNA Medicare |
$80.10
|
| Rate for Payer: HUMANA Commercial |
$80.10
|
| Rate for Payer: MEDICAID Medicaid |
$81.88
|
| Rate for Payer: MEDICARE Medicare |
$62.30
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$84.55
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$86.33
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$84.55
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$84.55
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$75.65
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$71.20
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$71.20
|
|
|
FINGER SPLINT, STATIC
|
Facility
IP
|
$22.00
|
|
|
Service Code
|
CPT Q4049
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$15.40 |
| Max. Negotiated Rate |
$22.00 |
| Rate for Payer: AETNA Commercial |
$20.90
|
| Rate for Payer: AETNA Medicare |
$19.80
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$20.90
|
| Rate for Payer: BCBS Healthlink |
$19.80
|
| Rate for Payer: BCBS HMK CHIP |
$19.80
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$19.80
|
| Rate for Payer: BCBS POS |
$20.90
|
| Rate for Payer: BCBS Traditional |
$22.00
|
| Rate for Payer: CASH_PRICE |
$17.60
|
| Rate for Payer: CIGNA Commercial |
$20.90
|
| Rate for Payer: CIGNA Medicare |
$19.80
|
| Rate for Payer: HUMANA Commercial |
$19.80
|
| Rate for Payer: MEDICAID Medicaid |
$20.24
|
| Rate for Payer: MEDICARE Medicare |
$15.40
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$20.90
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$21.34
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$20.90
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$20.90
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$18.70
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$17.60
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$17.60
|
|
|
FINGER SPLINT, STATIC
|
Facility
OP
|
$22.00
|
|
|
Service Code
|
CPT Q4049
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$15.40 |
| Max. Negotiated Rate |
$22.00 |
| Rate for Payer: AETNA Commercial |
$20.90
|
| Rate for Payer: AETNA Medicare |
$19.80
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$20.90
|
| Rate for Payer: BCBS Healthlink |
$19.80
|
| Rate for Payer: BCBS HMK CHIP |
$19.80
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$19.80
|
| Rate for Payer: BCBS POS |
$20.90
|
| Rate for Payer: BCBS Traditional |
$22.00
|
| Rate for Payer: CASH_PRICE |
$17.60
|
| Rate for Payer: CIGNA Commercial |
$20.90
|
| Rate for Payer: CIGNA Medicare |
$19.80
|
| Rate for Payer: HUMANA Commercial |
$19.80
|
| Rate for Payer: MEDICAID Medicaid |
$20.24
|
| Rate for Payer: MEDICARE Medicare |
$15.40
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$20.90
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$21.34
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$20.90
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$20.90
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$18.70
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$17.60
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$17.60
|
|
|
FISH OIL CAP [1000 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: BCBS HMK CHIP |
$7.20
|
| 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 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
|
|
|
FISH OIL CAP [1000 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
|
|
|
FITRIGHT INCONTIENT LINER
|
Facility
OP
|
$79.00
|
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$55.30 |
| Max. Negotiated Rate |
$79.00 |
| Rate for Payer: AETNA Commercial |
$75.05
|
| Rate for Payer: AETNA Medicare |
$71.10
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$75.05
|
| Rate for Payer: BCBS Healthlink |
$71.10
|
| Rate for Payer: BCBS HMK CHIP |
$71.10
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$71.10
|
| Rate for Payer: BCBS POS |
$75.05
|
| Rate for Payer: BCBS Traditional |
$79.00
|
| Rate for Payer: CASH_PRICE |
$63.20
|
| Rate for Payer: CIGNA Commercial |
$75.05
|
| Rate for Payer: CIGNA Medicare |
$71.10
|
| Rate for Payer: HUMANA Commercial |
$71.10
|
| Rate for Payer: MEDICAID Medicaid |
$72.68
|
| Rate for Payer: MEDICARE Medicare |
$55.30
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$75.05
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$76.63
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$75.05
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$75.05
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$67.15
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$63.20
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$63.20
|
|
|
FITRIGHT INCONTIENT LINER
|
Facility
IP
|
$79.00
|
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$55.30 |
| Max. Negotiated Rate |
$79.00 |
| Rate for Payer: AETNA Commercial |
$75.05
|
| Rate for Payer: AETNA Medicare |
$71.10
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$75.05
|
| Rate for Payer: BCBS Healthlink |
$71.10
|
| Rate for Payer: BCBS HMK CHIP |
$71.10
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$71.10
|
| Rate for Payer: BCBS POS |
$75.05
|
| Rate for Payer: BCBS Traditional |
$79.00
|
| Rate for Payer: CASH_PRICE |
$63.20
|
| Rate for Payer: CIGNA Commercial |
$75.05
|
| Rate for Payer: CIGNA Medicare |
$71.10
|
| Rate for Payer: HUMANA Commercial |
$71.10
|
| Rate for Payer: MEDICAID Medicaid |
$72.68
|
| Rate for Payer: MEDICARE Medicare |
$55.30
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$75.05
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$76.63
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$75.05
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$75.05
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$67.15
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$63.20
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$63.20
|
|
|
FIXODENT
|
Facility
OP
|
$32.00
|
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$22.40 |
| Max. Negotiated Rate |
$32.00 |
| Rate for Payer: AETNA Commercial |
$30.40
|
| Rate for Payer: AETNA Medicare |
$28.80
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$30.40
|
| Rate for Payer: BCBS Healthlink |
$28.80
|
| Rate for Payer: BCBS HMK CHIP |
$28.80
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$28.80
|
| Rate for Payer: BCBS POS |
$30.40
|
| Rate for Payer: BCBS Traditional |
$32.00
|
| Rate for Payer: CASH_PRICE |
$25.60
|
| Rate for Payer: CIGNA Commercial |
$30.40
|
| Rate for Payer: CIGNA Medicare |
$28.80
|
| Rate for Payer: HUMANA Commercial |
$28.80
|
| Rate for Payer: MEDICAID Medicaid |
$29.44
|
| Rate for Payer: MEDICARE Medicare |
$22.40
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$30.40
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$31.04
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$30.40
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$30.40
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$27.20
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$25.60
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$25.60
|
|
|
FIXODENT
|
Facility
IP
|
$32.00
|
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$22.40 |
| Max. Negotiated Rate |
$32.00 |
| Rate for Payer: BCBS HMK CHIP |
$28.80
|
| Rate for Payer: AETNA Commercial |
$30.40
|
| Rate for Payer: AETNA Medicare |
$28.80
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$30.40
|
| Rate for Payer: BCBS Healthlink |
$28.80
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$28.80
|
| Rate for Payer: BCBS POS |
$30.40
|
| Rate for Payer: BCBS Traditional |
$32.00
|
| Rate for Payer: CASH_PRICE |
$25.60
|
| Rate for Payer: CIGNA Commercial |
$30.40
|
| Rate for Payer: CIGNA Medicare |
$28.80
|
| Rate for Payer: HUMANA Commercial |
$28.80
|
| Rate for Payer: MEDICAID Medicaid |
$29.44
|
| Rate for Payer: MEDICARE Medicare |
$22.40
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$30.40
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$31.04
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$30.40
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$30.40
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$27.20
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$25.60
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$25.60
|
|
|
FLECAINIDE 50MG TAB NON FORMULARY
|
Facility
OP
|
$59.00
|
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$41.30 |
| Max. Negotiated Rate |
$59.00 |
| Rate for Payer: AETNA Commercial |
$56.05
|
| Rate for Payer: AETNA Medicare |
$53.10
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$56.05
|
| Rate for Payer: BCBS Healthlink |
$53.10
|
| Rate for Payer: BCBS HMK CHIP |
$53.10
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$53.10
|
| Rate for Payer: BCBS POS |
$56.05
|
| Rate for Payer: BCBS Traditional |
$59.00
|
| Rate for Payer: CASH_PRICE |
$47.20
|
| Rate for Payer: CIGNA Commercial |
$56.05
|
| Rate for Payer: CIGNA Medicare |
$53.10
|
| Rate for Payer: HUMANA Commercial |
$53.10
|
| Rate for Payer: MEDICAID Medicaid |
$54.28
|
| Rate for Payer: MEDICARE Medicare |
$41.30
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$56.05
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$57.23
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$56.05
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$56.05
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$50.15
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$47.20
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$47.20
|
|
|
FLECAINIDE 50MG TAB NON FORMULARY
|
Facility
IP
|
$59.00
|
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$41.30 |
| Max. Negotiated Rate |
$59.00 |
| Rate for Payer: AETNA Commercial |
$56.05
|
| Rate for Payer: AETNA Medicare |
$53.10
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$56.05
|
| Rate for Payer: BCBS Healthlink |
$53.10
|
| Rate for Payer: BCBS HMK CHIP |
$53.10
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$53.10
|
| Rate for Payer: BCBS POS |
$56.05
|
| Rate for Payer: BCBS Traditional |
$59.00
|
| Rate for Payer: CASH_PRICE |
$47.20
|
| Rate for Payer: CIGNA Commercial |
$56.05
|
| Rate for Payer: CIGNA Medicare |
$53.10
|
| Rate for Payer: HUMANA Commercial |
$53.10
|
| Rate for Payer: MEDICAID Medicaid |
$54.28
|
| Rate for Payer: MEDICARE Medicare |
$41.30
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$56.05
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$57.23
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$56.05
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$56.05
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$50.15
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$47.20
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$47.20
|
|
|
.FLOW CYTOMETRY, EACH ADDITIONAL MARKER
|
Facility
IP
|
$238.00
|
|
|
Service Code
|
CPT 88185
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
310
|
| Min. Negotiated Rate |
$166.60 |
| Max. Negotiated Rate |
$238.00 |
| Rate for Payer: AETNA Commercial |
$226.10
|
| Rate for Payer: AETNA Medicare |
$214.20
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$226.10
|
| Rate for Payer: BCBS Healthlink |
$214.20
|
| Rate for Payer: BCBS HMK CHIP |
$214.20
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$214.20
|
| Rate for Payer: BCBS POS |
$226.10
|
| Rate for Payer: BCBS Traditional |
$238.00
|
| Rate for Payer: CASH_PRICE |
$190.40
|
| Rate for Payer: CIGNA Commercial |
$226.10
|
| Rate for Payer: CIGNA Medicare |
$214.20
|
| Rate for Payer: HUMANA Commercial |
$214.20
|
| Rate for Payer: MEDICAID Medicaid |
$218.96
|
| Rate for Payer: MEDICARE Medicare |
$166.60
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$226.10
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$230.86
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$226.10
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$226.10
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$202.30
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$190.40
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$190.40
|
|
|
.FLOW CYTOMETRY, EACH ADDITIONAL MARKER
|
Facility
OP
|
$238.00
|
|
|
Service Code
|
CPT 88185
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
310
|
| Min. Negotiated Rate |
$166.60 |
| Max. Negotiated Rate |
$238.00 |
| Rate for Payer: AETNA Commercial |
$226.10
|
| Rate for Payer: AETNA Medicare |
$214.20
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$226.10
|
| Rate for Payer: BCBS Healthlink |
$214.20
|
| Rate for Payer: BCBS HMK CHIP |
$214.20
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$214.20
|
| Rate for Payer: BCBS POS |
$226.10
|
| Rate for Payer: BCBS Traditional |
$238.00
|
| Rate for Payer: CASH_PRICE |
$190.40
|
| Rate for Payer: CIGNA Commercial |
$226.10
|
| Rate for Payer: CIGNA Medicare |
$214.20
|
| Rate for Payer: HUMANA Commercial |
$214.20
|
| Rate for Payer: MEDICAID Medicaid |
$218.96
|
| Rate for Payer: MEDICARE Medicare |
$166.60
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$226.10
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$230.86
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$226.10
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$226.10
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$202.30
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$190.40
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$190.40
|
|
|
.FLOW CYTOMETRY, FIRST MARKER
|
Facility
OP
|
$342.00
|
|
|
Service Code
|
CPT 88184
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
310
|
| Min. Negotiated Rate |
$239.40 |
| Max. Negotiated Rate |
$342.00 |
| Rate for Payer: AETNA Commercial |
$324.90
|
| Rate for Payer: AETNA Medicare |
$307.80
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$324.90
|
| Rate for Payer: BCBS Healthlink |
$307.80
|
| Rate for Payer: BCBS HMK CHIP |
$307.80
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$307.80
|
| Rate for Payer: BCBS POS |
$324.90
|
| Rate for Payer: BCBS Traditional |
$342.00
|
| Rate for Payer: CASH_PRICE |
$273.60
|
| Rate for Payer: CIGNA Commercial |
$324.90
|
| Rate for Payer: CIGNA Medicare |
$307.80
|
| Rate for Payer: HUMANA Commercial |
$307.80
|
| Rate for Payer: MEDICAID Medicaid |
$314.64
|
| Rate for Payer: MEDICARE Medicare |
$239.40
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$324.90
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$331.74
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$324.90
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$324.90
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$290.70
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$273.60
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$273.60
|
|
|
.FLOW CYTOMETRY, FIRST MARKER
|
Facility
IP
|
$342.00
|
|
|
Service Code
|
CPT 88184
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
310
|
| Min. Negotiated Rate |
$239.40 |
| Max. Negotiated Rate |
$342.00 |
| Rate for Payer: BCBS HMK CHIP |
$307.80
|
| Rate for Payer: AETNA Commercial |
$324.90
|
| Rate for Payer: AETNA Medicare |
$307.80
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$324.90
|
| Rate for Payer: BCBS Healthlink |
$307.80
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$307.80
|
| Rate for Payer: BCBS POS |
$324.90
|
| Rate for Payer: BCBS Traditional |
$342.00
|
| Rate for Payer: CASH_PRICE |
$273.60
|
| Rate for Payer: CIGNA Commercial |
$324.90
|
| Rate for Payer: CIGNA Medicare |
$307.80
|
| Rate for Payer: HUMANA Commercial |
$307.80
|
| Rate for Payer: MEDICAID Medicaid |
$314.64
|
| Rate for Payer: MEDICARE Medicare |
$239.40
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$324.90
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$331.74
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$324.90
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$324.90
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$290.70
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$273.60
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$273.60
|
|
|
.FLOW CYTOMETRY, INTERPRETATION
|
Facility
IP
|
$238.00
|
|
|
Service Code
|
CPT 88187
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
310
|
| Min. Negotiated Rate |
$166.60 |
| Max. Negotiated Rate |
$238.00 |
| Rate for Payer: AETNA Commercial |
$226.10
|
| Rate for Payer: AETNA Medicare |
$214.20
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$226.10
|
| Rate for Payer: BCBS Healthlink |
$214.20
|
| Rate for Payer: BCBS HMK CHIP |
$214.20
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$214.20
|
| Rate for Payer: BCBS POS |
$226.10
|
| Rate for Payer: BCBS Traditional |
$238.00
|
| Rate for Payer: CASH_PRICE |
$190.40
|
| Rate for Payer: CIGNA Commercial |
$226.10
|
| Rate for Payer: CIGNA Medicare |
$214.20
|
| Rate for Payer: HUMANA Commercial |
$214.20
|
| Rate for Payer: MEDICAID Medicaid |
$218.96
|
| Rate for Payer: MEDICARE Medicare |
$166.60
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$226.10
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$230.86
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$226.10
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$226.10
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$202.30
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$190.40
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$190.40
|
|
|
.FLOW CYTOMETRY, INTERPRETATION
|
Facility
OP
|
$238.00
|
|
|
Service Code
|
CPT 88187
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
310
|
| Min. Negotiated Rate |
$166.60 |
| Max. Negotiated Rate |
$238.00 |
| Rate for Payer: AETNA Commercial |
$226.10
|
| Rate for Payer: AETNA Medicare |
$214.20
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$226.10
|
| Rate for Payer: BCBS Healthlink |
$214.20
|
| Rate for Payer: BCBS HMK CHIP |
$214.20
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$214.20
|
| Rate for Payer: BCBS POS |
$226.10
|
| Rate for Payer: BCBS Traditional |
$238.00
|
| Rate for Payer: CASH_PRICE |
$190.40
|
| Rate for Payer: CIGNA Commercial |
$226.10
|
| Rate for Payer: CIGNA Medicare |
$214.20
|
| Rate for Payer: HUMANA Commercial |
$214.20
|
| Rate for Payer: MEDICAID Medicaid |
$218.96
|
| Rate for Payer: MEDICARE Medicare |
$166.60
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$226.10
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$230.86
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$226.10
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$226.10
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$202.30
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$190.40
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$190.40
|
|
|
FLUCONAZOLE 100 MG TABLET
|
Facility
OP
|
$28.00
|
|
| Hospital Charge Code |
20230406
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$19.60 |
| Max. Negotiated Rate |
$28.00 |
| Rate for Payer: AETNA Commercial |
$26.60
|
| Rate for Payer: AETNA Medicare |
$25.20
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$26.60
|
| Rate for Payer: BCBS Healthlink |
$25.20
|
| Rate for Payer: BCBS HMK CHIP |
$25.20
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$25.20
|
| Rate for Payer: BCBS POS |
$26.60
|
| Rate for Payer: BCBS Traditional |
$28.00
|
| Rate for Payer: CASH_PRICE |
$22.40
|
| Rate for Payer: CIGNA Commercial |
$26.60
|
| Rate for Payer: CIGNA Medicare |
$25.20
|
| Rate for Payer: HUMANA Commercial |
$25.20
|
| Rate for Payer: MEDICAID Medicaid |
$25.76
|
| Rate for Payer: MEDICARE Medicare |
$19.60
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$26.60
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$27.16
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$26.60
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$26.60
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$23.80
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$22.40
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$22.40
|
|
|
FLUCONAZOLE 100 MG TABLET
|
Facility
IP
|
$28.00
|
|
| Hospital Charge Code |
20230406
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$19.60 |
| Max. Negotiated Rate |
$28.00 |
| Rate for Payer: BCBS HMK CHIP |
$25.20
|
| Rate for Payer: AETNA Commercial |
$26.60
|
| Rate for Payer: AETNA Medicare |
$25.20
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$26.60
|
| Rate for Payer: BCBS Healthlink |
$25.20
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$25.20
|
| Rate for Payer: BCBS POS |
$26.60
|
| Rate for Payer: BCBS Traditional |
$28.00
|
| Rate for Payer: CASH_PRICE |
$22.40
|
| Rate for Payer: CIGNA Commercial |
$26.60
|
| Rate for Payer: CIGNA Medicare |
$25.20
|
| Rate for Payer: HUMANA Commercial |
$25.20
|
| Rate for Payer: MEDICAID Medicaid |
$25.76
|
| Rate for Payer: MEDICARE Medicare |
$19.60
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$26.60
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$27.16
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$26.60
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$26.60
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$23.80
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$22.40
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$22.40
|
|
