|
FX CLOSED TIBIA SHAFT W/O MANIPULA
|
Facility
IP
|
$823.00
|
|
|
Service Code
|
CPT 27750
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$576.10 |
| Max. Negotiated Rate |
$823.00 |
| Rate for Payer: AETNA Commercial |
$781.85
|
| Rate for Payer: AETNA Medicare |
$740.70
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$781.85
|
| Rate for Payer: BCBS Healthlink |
$740.70
|
| Rate for Payer: BCBS HMK CHIP |
$740.70
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$740.70
|
| Rate for Payer: BCBS POS |
$781.85
|
| Rate for Payer: BCBS Traditional |
$823.00
|
| Rate for Payer: CASH_PRICE |
$658.40
|
| Rate for Payer: CIGNA Commercial |
$781.85
|
| Rate for Payer: CIGNA Medicare |
$740.70
|
| Rate for Payer: HUMANA Commercial |
$740.70
|
| Rate for Payer: MEDICAID Medicaid |
$757.16
|
| Rate for Payer: MEDICARE Medicare |
$576.10
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$781.85
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$798.31
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$781.85
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$781.85
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$699.55
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$658.40
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$658.40
|
|
|
G6PD ENZYME ACTIVITY (121003)
|
Facility
IP
|
$82.00
|
|
|
Service Code
|
CPT 82955
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$57.40 |
| Max. Negotiated Rate |
$82.00 |
| Rate for Payer: AETNA Commercial |
$77.90
|
| Rate for Payer: AETNA Medicare |
$73.80
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$77.90
|
| Rate for Payer: BCBS Healthlink |
$73.80
|
| Rate for Payer: BCBS HMK CHIP |
$73.80
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$73.80
|
| Rate for Payer: BCBS POS |
$77.90
|
| Rate for Payer: BCBS Traditional |
$82.00
|
| Rate for Payer: CASH_PRICE |
$65.60
|
| Rate for Payer: CIGNA Commercial |
$77.90
|
| Rate for Payer: CIGNA Medicare |
$73.80
|
| Rate for Payer: HUMANA Commercial |
$73.80
|
| Rate for Payer: MEDICAID Medicaid |
$75.44
|
| Rate for Payer: MEDICARE Medicare |
$57.40
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$77.90
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$79.54
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$77.90
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$77.90
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$69.70
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$65.60
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$65.60
|
|
|
G6PD ENZYME ACTIVITY (121003)
|
Facility
OP
|
$82.00
|
|
|
Service Code
|
CPT 82955
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$57.40 |
| Max. Negotiated Rate |
$82.00 |
| Rate for Payer: AETNA Commercial |
$77.90
|
| Rate for Payer: AETNA Medicare |
$73.80
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$77.90
|
| Rate for Payer: BCBS Healthlink |
$73.80
|
| Rate for Payer: BCBS HMK CHIP |
$73.80
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$73.80
|
| Rate for Payer: BCBS POS |
$77.90
|
| Rate for Payer: BCBS Traditional |
$82.00
|
| Rate for Payer: CASH_PRICE |
$65.60
|
| Rate for Payer: CIGNA Commercial |
$77.90
|
| Rate for Payer: CIGNA Medicare |
$73.80
|
| Rate for Payer: HUMANA Commercial |
$73.80
|
| Rate for Payer: MEDICAID Medicaid |
$75.44
|
| Rate for Payer: MEDICARE Medicare |
$57.40
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$77.90
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$79.54
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$77.90
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$77.90
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$69.70
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$65.60
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$65.60
|
|
|
GABAPENTIN CAP [100 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
|
|
|
GABAPENTIN CAP [100 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
|
|
|
GABAPENTIN CAP [300 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
|
|
|
GABAPENTIN CAP [300 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
|
|
|
GASTRIN (004390)
|
Facility
IP
|
$142.00
|
|
|
Service Code
|
CPT 82941
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$99.40 |
| Max. Negotiated Rate |
$142.00 |
| Rate for Payer: BCBS HMK CHIP |
$127.80
|
| Rate for Payer: AETNA Commercial |
$134.90
|
| Rate for Payer: AETNA Medicare |
$127.80
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$134.90
|
| Rate for Payer: BCBS Healthlink |
$127.80
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$127.80
|
| Rate for Payer: BCBS POS |
$134.90
|
| Rate for Payer: BCBS Traditional |
$142.00
|
| Rate for Payer: CASH_PRICE |
$113.60
|
| Rate for Payer: CIGNA Commercial |
$134.90
|
| Rate for Payer: CIGNA Medicare |
$127.80
|
| Rate for Payer: HUMANA Commercial |
$127.80
|
| Rate for Payer: MEDICAID Medicaid |
$130.64
|
| Rate for Payer: MEDICARE Medicare |
$99.40
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$134.90
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$137.74
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$134.90
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$134.90
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$120.70
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$113.60
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$113.60
|
|
|
GASTRIN (004390)
|
Facility
OP
|
$142.00
|
|
|
Service Code
|
CPT 82941
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$99.40 |
| Max. Negotiated Rate |
$142.00 |
| Rate for Payer: AETNA Commercial |
$134.90
|
| Rate for Payer: AETNA Medicare |
$127.80
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$134.90
|
| Rate for Payer: BCBS Healthlink |
$127.80
|
| Rate for Payer: BCBS HMK CHIP |
$127.80
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$127.80
|
| Rate for Payer: BCBS POS |
$134.90
|
| Rate for Payer: BCBS Traditional |
$142.00
|
| Rate for Payer: CASH_PRICE |
$113.60
|
| Rate for Payer: CIGNA Commercial |
$134.90
|
| Rate for Payer: CIGNA Medicare |
$127.80
|
| Rate for Payer: HUMANA Commercial |
$127.80
|
| Rate for Payer: MEDICAID Medicaid |
$130.64
|
| Rate for Payer: MEDICARE Medicare |
$99.40
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$134.90
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$137.74
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$134.90
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$134.90
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$120.70
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$113.60
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$113.60
|
|
|
GASTROINTESTINAL PROFILE, PCR (183480)
|
Facility
IP
|
$792.00
|
|
|
Service Code
|
CPT 87507
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$554.40 |
| Max. Negotiated Rate |
$792.00 |
| Rate for Payer: AETNA Commercial |
$752.40
|
| Rate for Payer: AETNA Medicare |
$712.80
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$752.40
|
| Rate for Payer: BCBS Healthlink |
$712.80
|
| Rate for Payer: BCBS HMK CHIP |
$712.80
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$712.80
|
| Rate for Payer: BCBS POS |
$752.40
|
| Rate for Payer: BCBS Traditional |
$792.00
|
| Rate for Payer: CASH_PRICE |
$633.60
|
| Rate for Payer: CIGNA Commercial |
$752.40
|
| Rate for Payer: CIGNA Medicare |
$712.80
|
| Rate for Payer: HUMANA Commercial |
$712.80
|
| Rate for Payer: MEDICAID Medicaid |
$728.64
|
| Rate for Payer: MEDICARE Medicare |
$554.40
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$752.40
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$768.24
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$752.40
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$752.40
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$673.20
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$633.60
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$633.60
|
|
|
GASTROINTESTINAL PROFILE, PCR (183480)
|
Facility
OP
|
$792.00
|
|
|
Service Code
|
CPT 87507
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$554.40 |
| Max. Negotiated Rate |
$792.00 |
| Rate for Payer: AETNA Commercial |
$752.40
|
| Rate for Payer: AETNA Medicare |
$712.80
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$752.40
|
| Rate for Payer: BCBS Healthlink |
$712.80
|
| Rate for Payer: BCBS HMK CHIP |
$712.80
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$712.80
|
| Rate for Payer: BCBS POS |
$752.40
|
| Rate for Payer: BCBS Traditional |
$792.00
|
| Rate for Payer: CASH_PRICE |
$633.60
|
| Rate for Payer: CIGNA Commercial |
$752.40
|
| Rate for Payer: CIGNA Medicare |
$712.80
|
| Rate for Payer: HUMANA Commercial |
$712.80
|
| Rate for Payer: MEDICAID Medicaid |
$728.64
|
| Rate for Payer: MEDICARE Medicare |
$554.40
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$752.40
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$768.24
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$752.40
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$752.40
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$673.20
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$633.60
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$633.60
|
|
|
GAUZE 2 X 2 STERILE
|
Facility
IP
|
$4.00
|
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$2.80 |
| Max. Negotiated Rate |
$4.00 |
| Rate for Payer: BCBS HMK CHIP |
$3.60
|
| Rate for Payer: AETNA Commercial |
$3.80
|
| Rate for Payer: AETNA Medicare |
$3.60
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$3.80
|
| Rate for Payer: BCBS Healthlink |
$3.60
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$3.60
|
| Rate for Payer: BCBS POS |
$3.80
|
| Rate for Payer: BCBS Traditional |
$4.00
|
| Rate for Payer: CASH_PRICE |
$3.20
|
| Rate for Payer: CIGNA Commercial |
$3.80
|
| Rate for Payer: CIGNA Medicare |
$3.60
|
| Rate for Payer: HUMANA Commercial |
$3.60
|
| Rate for Payer: MEDICAID Medicaid |
$3.68
|
| Rate for Payer: MEDICARE Medicare |
$2.80
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$3.80
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$3.88
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$3.80
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$3.80
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$3.40
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$3.20
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$3.20
|
|
|
GAUZE 2 X 2 STERILE
|
Facility
OP
|
$4.00
|
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$2.80 |
| Max. Negotiated Rate |
$4.00 |
| Rate for Payer: AETNA Commercial |
$3.80
|
| Rate for Payer: AETNA Medicare |
$3.60
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$3.80
|
| Rate for Payer: BCBS Healthlink |
$3.60
|
| Rate for Payer: BCBS HMK CHIP |
$3.60
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$3.60
|
| Rate for Payer: BCBS POS |
$3.80
|
| Rate for Payer: BCBS Traditional |
$4.00
|
| Rate for Payer: CASH_PRICE |
$3.20
|
| Rate for Payer: CIGNA Commercial |
$3.80
|
| Rate for Payer: CIGNA Medicare |
$3.60
|
| Rate for Payer: HUMANA Commercial |
$3.60
|
| Rate for Payer: MEDICAID Medicaid |
$3.68
|
| Rate for Payer: MEDICARE Medicare |
$2.80
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$3.80
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$3.88
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$3.80
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$3.80
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$3.40
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$3.20
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$3.20
|
|
|
GAUZE 3 X 3 STERILE
|
Facility
IP
|
$4.00
|
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$2.80 |
| Max. Negotiated Rate |
$4.00 |
| Rate for Payer: AETNA Commercial |
$3.80
|
| Rate for Payer: AETNA Medicare |
$3.60
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$3.80
|
| Rate for Payer: BCBS Healthlink |
$3.60
|
| Rate for Payer: BCBS HMK CHIP |
$3.60
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$3.60
|
| Rate for Payer: BCBS POS |
$3.80
|
| Rate for Payer: BCBS Traditional |
$4.00
|
| Rate for Payer: CASH_PRICE |
$3.20
|
| Rate for Payer: CIGNA Commercial |
$3.80
|
| Rate for Payer: CIGNA Medicare |
$3.60
|
| Rate for Payer: HUMANA Commercial |
$3.60
|
| Rate for Payer: MEDICAID Medicaid |
$3.68
|
| Rate for Payer: MEDICARE Medicare |
$2.80
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$3.80
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$3.88
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$3.80
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$3.80
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$3.40
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$3.20
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$3.20
|
|
|
GAUZE 3 X 3 STERILE
|
Facility
OP
|
$4.00
|
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$2.80 |
| Max. Negotiated Rate |
$4.00 |
| Rate for Payer: AETNA Commercial |
$3.80
|
| Rate for Payer: AETNA Medicare |
$3.60
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$3.80
|
| Rate for Payer: BCBS Healthlink |
$3.60
|
| Rate for Payer: BCBS HMK CHIP |
$3.60
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$3.60
|
| Rate for Payer: BCBS POS |
$3.80
|
| Rate for Payer: BCBS Traditional |
$4.00
|
| Rate for Payer: CASH_PRICE |
$3.20
|
| Rate for Payer: CIGNA Commercial |
$3.80
|
| Rate for Payer: CIGNA Medicare |
$3.60
|
| Rate for Payer: HUMANA Commercial |
$3.60
|
| Rate for Payer: MEDICAID Medicaid |
$3.68
|
| Rate for Payer: MEDICARE Medicare |
$2.80
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$3.80
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$3.88
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$3.80
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$3.80
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$3.40
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$3.20
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$3.20
|
|
|
GAUZE 4 X 4 IN PEEL BACK TRAY
|
Facility
IP
|
$30.00
|
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$21.00 |
| Max. Negotiated Rate |
$30.00 |
| Rate for Payer: BCBS HMK CHIP |
$27.00
|
| Rate for Payer: AETNA Commercial |
$28.50
|
| Rate for Payer: AETNA Medicare |
$27.00
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$28.50
|
| Rate for Payer: BCBS Healthlink |
$27.00
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$27.00
|
| Rate for Payer: BCBS POS |
$28.50
|
| Rate for Payer: BCBS Traditional |
$30.00
|
| Rate for Payer: CASH_PRICE |
$24.00
|
| Rate for Payer: CIGNA Commercial |
$28.50
|
| Rate for Payer: CIGNA Medicare |
$27.00
|
| Rate for Payer: HUMANA Commercial |
$27.00
|
| Rate for Payer: MEDICAID Medicaid |
$27.60
|
| Rate for Payer: MEDICARE Medicare |
$21.00
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$28.50
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$29.10
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$28.50
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$28.50
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$25.50
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$24.00
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$24.00
|
|
|
GAUZE 4 X 4 IN PEEL BACK TRAY
|
Facility
OP
|
$30.00
|
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$21.00 |
| Max. Negotiated Rate |
$30.00 |
| Rate for Payer: AETNA Commercial |
$28.50
|
| Rate for Payer: AETNA Medicare |
$27.00
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$28.50
|
| Rate for Payer: BCBS Healthlink |
$27.00
|
| Rate for Payer: BCBS HMK CHIP |
$27.00
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$27.00
|
| Rate for Payer: BCBS POS |
$28.50
|
| Rate for Payer: BCBS Traditional |
$30.00
|
| Rate for Payer: CASH_PRICE |
$24.00
|
| Rate for Payer: CIGNA Commercial |
$28.50
|
| Rate for Payer: CIGNA Medicare |
$27.00
|
| Rate for Payer: HUMANA Commercial |
$27.00
|
| Rate for Payer: MEDICAID Medicaid |
$27.60
|
| Rate for Payer: MEDICARE Medicare |
$21.00
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$28.50
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$29.10
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$28.50
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$28.50
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$25.50
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$24.00
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$24.00
|
|
|
GAUZE 4 X 4 STERILE
|
Facility
OP
|
$4.00
|
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$2.80 |
| Max. Negotiated Rate |
$4.00 |
| Rate for Payer: AETNA Commercial |
$3.80
|
| Rate for Payer: AETNA Medicare |
$3.60
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$3.80
|
| Rate for Payer: BCBS Healthlink |
$3.60
|
| Rate for Payer: BCBS HMK CHIP |
$3.60
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$3.60
|
| Rate for Payer: BCBS POS |
$3.80
|
| Rate for Payer: BCBS Traditional |
$4.00
|
| Rate for Payer: CASH_PRICE |
$3.20
|
| Rate for Payer: CIGNA Commercial |
$3.80
|
| Rate for Payer: CIGNA Medicare |
$3.60
|
| Rate for Payer: HUMANA Commercial |
$3.60
|
| Rate for Payer: MEDICAID Medicaid |
$3.68
|
| Rate for Payer: MEDICARE Medicare |
$2.80
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$3.80
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$3.88
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$3.80
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$3.80
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$3.40
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$3.20
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$3.20
|
|
|
GAUZE 4 X 4 STERILE
|
Facility
IP
|
$4.00
|
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$2.80 |
| Max. Negotiated Rate |
$4.00 |
| Rate for Payer: AETNA Commercial |
$3.80
|
| Rate for Payer: AETNA Medicare |
$3.60
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$3.80
|
| Rate for Payer: BCBS Healthlink |
$3.60
|
| Rate for Payer: BCBS HMK CHIP |
$3.60
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$3.60
|
| Rate for Payer: BCBS POS |
$3.80
|
| Rate for Payer: BCBS Traditional |
$4.00
|
| Rate for Payer: CASH_PRICE |
$3.20
|
| Rate for Payer: CIGNA Commercial |
$3.80
|
| Rate for Payer: CIGNA Medicare |
$3.60
|
| Rate for Payer: HUMANA Commercial |
$3.60
|
| Rate for Payer: MEDICAID Medicaid |
$3.68
|
| Rate for Payer: MEDICARE Medicare |
$2.80
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$3.80
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$3.88
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$3.80
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$3.80
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$3.40
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$3.20
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$3.20
|
|
|
GENITAL CULTURE (008334)
|
Facility
OP
|
$37.00
|
|
|
Service Code
|
CPT 87070
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$25.90 |
| Max. Negotiated Rate |
$37.00 |
| Rate for Payer: AETNA Commercial |
$35.15
|
| Rate for Payer: AETNA Medicare |
$33.30
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$35.15
|
| Rate for Payer: BCBS Healthlink |
$33.30
|
| Rate for Payer: BCBS HMK CHIP |
$33.30
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$33.30
|
| Rate for Payer: BCBS POS |
$35.15
|
| Rate for Payer: BCBS Traditional |
$37.00
|
| Rate for Payer: CASH_PRICE |
$29.60
|
| Rate for Payer: CIGNA Commercial |
$35.15
|
| Rate for Payer: CIGNA Medicare |
$33.30
|
| Rate for Payer: HUMANA Commercial |
$33.30
|
| Rate for Payer: MEDICAID Medicaid |
$34.04
|
| Rate for Payer: MEDICARE Medicare |
$25.90
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$35.15
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$35.89
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$35.15
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$35.15
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$31.45
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$29.60
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$29.60
|
|
|
GENITAL CULTURE (008334)
|
Facility
IP
|
$37.00
|
|
|
Service Code
|
CPT 87070
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$25.90 |
| Max. Negotiated Rate |
$37.00 |
| Rate for Payer: BCBS HMK CHIP |
$33.30
|
| Rate for Payer: AETNA Commercial |
$35.15
|
| Rate for Payer: AETNA Medicare |
$33.30
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$35.15
|
| Rate for Payer: BCBS Healthlink |
$33.30
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$33.30
|
| Rate for Payer: BCBS POS |
$35.15
|
| Rate for Payer: BCBS Traditional |
$37.00
|
| Rate for Payer: CASH_PRICE |
$29.60
|
| Rate for Payer: CIGNA Commercial |
$35.15
|
| Rate for Payer: CIGNA Medicare |
$33.30
|
| Rate for Payer: HUMANA Commercial |
$33.30
|
| Rate for Payer: MEDICAID Medicaid |
$34.04
|
| Rate for Payer: MEDICARE Medicare |
$25.90
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$35.15
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$35.89
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$35.15
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$35.15
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$31.45
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$29.60
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$29.60
|
|
|
GENTAMICIN 0.3% OPHTH DROPS
|
Facility
IP
|
$65.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$45.50 |
| Max. Negotiated Rate |
$65.00 |
| Rate for Payer: AETNA Commercial |
$61.75
|
| Rate for Payer: AETNA Medicare |
$58.50
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$61.75
|
| Rate for Payer: BCBS Healthlink |
$58.50
|
| Rate for Payer: BCBS HMK CHIP |
$58.50
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$58.50
|
| Rate for Payer: BCBS POS |
$61.75
|
| Rate for Payer: BCBS Traditional |
$65.00
|
| Rate for Payer: CASH_PRICE |
$52.00
|
| Rate for Payer: CIGNA Commercial |
$61.75
|
| Rate for Payer: CIGNA Medicare |
$58.50
|
| Rate for Payer: HUMANA Commercial |
$58.50
|
| Rate for Payer: MEDICAID Medicaid |
$59.80
|
| Rate for Payer: MEDICARE Medicare |
$45.50
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$61.75
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$63.05
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$61.75
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$61.75
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$55.25
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$52.00
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$52.00
|
|
|
GENTAMICIN 0.3% OPHTH DROPS
|
Facility
OP
|
$65.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$45.50 |
| Max. Negotiated Rate |
$65.00 |
| Rate for Payer: AETNA Commercial |
$61.75
|
| Rate for Payer: AETNA Medicare |
$58.50
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$61.75
|
| Rate for Payer: BCBS Healthlink |
$58.50
|
| Rate for Payer: BCBS HMK CHIP |
$58.50
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$58.50
|
| Rate for Payer: BCBS POS |
$61.75
|
| Rate for Payer: BCBS Traditional |
$65.00
|
| Rate for Payer: CASH_PRICE |
$52.00
|
| Rate for Payer: CIGNA Commercial |
$61.75
|
| Rate for Payer: CIGNA Medicare |
$58.50
|
| Rate for Payer: HUMANA Commercial |
$58.50
|
| Rate for Payer: MEDICAID Medicaid |
$59.80
|
| Rate for Payer: MEDICARE Medicare |
$45.50
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$61.75
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$63.05
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$61.75
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$61.75
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$55.25
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$52.00
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$52.00
|
|
|
GENTAMICIN INJ [80 MG/2 ML]
|
Facility
OP
|
$25.00
|
|
|
Service Code
|
CPT J1580
|
| Hospital Charge Code |
20220608
|
|
Hospital Revenue Code
|
636
|
| 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
|
|
|
GENTAMICIN INJ [80 MG/2 ML]
|
Facility
IP
|
$25.00
|
|
|
Service Code
|
CPT J1580
|
| Hospital Charge Code |
20220608
|
|
Hospital Revenue Code
|
636
|
| 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
|
|
