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FEE SCHEDULE, BASE YEAR
BLACKFEET COMMUNITY HOSPITAL BROWNING, MONTANA
RED BLOOD CELLS, RBC Fee RBC - Leukoreduced RBC - Non-Leukoreduced (autologous only) RBC - Washed RBC - Deglycerolyzed RBC - Divided
WHOLE BLOOD
Whole Blood (autologous only) Whole Blood - Leukoreduced (autologous only)
FROZEN PLASMA
Plasma - Frozen within 24 hours Plasma - Fresh Frozen (limited availability) Plasma - Divided Plasma - Cryo-reduced
CRYOPRECIPITATED ANTI-HEMOPHILIAC FACTOR
Cryoprecipitated-AHF Pooled Cryoprecipitated-AHF (pool of 5)
PLATELET PRODUCTS AND SERVICES
Plateletpheresis - Leukoreduced
Platelet Additive Solution Plateletpheresis - Leukoreduced
Granulocytes Pheresis
Granulocyte Cancellation After Set Up
| A7I |
| HLA Matched Platelet Surcharge, per unit |
| J5I |
| Platelet Component, Crossmatched |
| 91021 |
| Leukocyte Antibody Identification |
| 91029 |
| Platelet Antibody, each technique |
| HLA009 |
| HLA Antibody Testing by ELISA |
AUTOLOGOUS/DIRECTED
Autologous Surcharge, per unit
Directed Surcharge, per unit
SPECIAL
| IRRD |
| Irradiation Surcharge, per unit |
| P1M |
| Four Empty Bags Attached Surcharge, per unit |
REFERENCE LAB
Call-In / Stat Fee - applied for services requested after 4:30PM on weekdays or anytime on weekends or holidays for reference lab services.
| 66128 |
| Call-In Fee for Patient Sample Testing, first 2 hours |
| REF31 |
| Call-In Fee for Patient Sample Testing, Extra Hours, per hour |
| T4I |
| Call-In Fee for Antigen Negative Requests, Screening Required |
BLACKFEET COMMUNITY HOSPITAL, BROWNING, MT
Description Fee
| C5I |
| Import Fee, Rare Product |
| D5I |
| Search fee, Rare Product |
| B6I |
| Hemoglobin S, per test |
| 86850 |
| Antibody Screen, each media |
| 86870 |
| Antibody ID, each panel & media |
| 86886 |
| Indirect Titer, per antibody |
| G5I |
| Antigen Type, not labeled - segment test/report, per antigen, per unit |
| H5I |
| Antigen Screen with Patient Serum, per antigen, per unit |
| 86905 |
| RBC Antigen Other Than ABO/D, each |
| 86906 |
| Rh Phenotyping, complete |
| 86920 |
| Immediate Spin Crossmatch |
| O5I |
| AGT Phase of Crossmatch, includes incubation of crossmatch |
| 86970 |
| Pretreatment of Cells With Chemical Agents or Drugs, per cell |
| 86971 |
| Pretreatment With Enzymes, per cell |
| 86972 |
| Separation by Density Gradient, reticulocytes |
| 86975 |
| Incubation: serum & drugs, each |
| 86976 |
| Dilution of Serum, per aliquot |
| 86977 |
| Incubation with Inhibitors, per aliquot |
| 86978 |
| Differential/Auto Adsorption of Serum, each |
| A4I |
| Red Cell Antigen Negative, 1 antigen per unit |
| B4I |
| Red Cell Antigen Negative, 2 antigens per unit |
| C4I |
| Red Cell Antigen Negative, 3 antigens per unit |
| D4I |
| Red Cell Antigen Negative, 4 antigens per unit |
| E4I |
| Red Cell Antigen Negative, 5 antigens per unit |
| F4I |
| Red Cell Antigen Negative, 6 antigens per unit |
| G4I |
| Red Cell Antigen Negative, 7 antigens per unit |
| H4I |
| Red Cell Antigen Negative, 8 antigens per unit |
| I4I |
| Red Cell Antigen Negative, 9 antigens per unit |
| REF12 |
| Miscellaneous Adsorption, per adsorption |
| REF13 |
| Complex Preparation of Patient Cells for Adsorption |
| REF14 |
| Thawing Rare Reagent Red Cells, per cell |
| REF18 |
| Segment Procurement, per ten segments |
| REF23 |
| NRLBGS Referral Fee, fees dependent upon tests requested |
A5I RBC Antigen Negative, Rare Unit Fee; for each request for units of frequency less than 2% of the population and/or >75 units screened.
Prorated billing for screening of <75 units as follows:
| J4I |
| Antigen screening, 1-10 units |
| K4I |
| Antigen screening, 11-20 units |
| L4I |
| Antigen screening, 21-30 units |
| M4I |
| Antigen screening, 31-40 units |
| N4I |
| Antigen screening, 41-50 units |
| O4I |
| Antigen screening, 51-60 units |
| P4I |
| Antigen screening, 61-74 units |
FEE SCHEDULE, OPTION YEAR ONE
RED BLOOD CELLS, RBC Fee RBC - Leukoreduced RBC - Non-Leukoreduced (autologous only) RBC - Washed RBC - Deglycerolyzed RBC - Divided
WHOLE BLOOD
Whole Blood (autologous only) Whole Blood - Leukoreduced (autologous only)
FROZEN PLASMA
Plasma - Frozen within 24 hours Plasma - Fresh Frozen (limited availability) Plasma - Divided Plasma - Cryo-reduced
CRYOPRECIPITATED ANTI-HEMOPHILIAC FACTOR
Cryoprecipitated-AHF Pooled Cryoprecipitated-AHF (pool of 5)
Plateletpheresis - Leukoreduced
Platelet Additive Solution Plateletpheresis - Leukoreduced
Granulocytes Pheresis
Granulocyte Cancellation After Set Up
| A7I |
| HLA Matched Platelet Surcharge, per unit |
| J5I |
| Platelet Component, Crossmatched |
| 91021 |
| Leukocyte Antibody Identification |
| 91029 |
| Platelet Antibody, each technique |
| HLA009 |
| HLA Antibody Testing by ELISA |
Autologous Surcharge, per unit
Directed Surcharge, per unit
| IRRD |
| Irradiation Surcharge, per unit |
| P1M |
| Four Empty Bags Attached Surcharge, per unit |
Call-In / Stat Fee - applied for services requested after 4:30PM on
| 66128 |
| Call-In Fee for Patient Sample Testing, first 2 hours |
| REF31 |
| Call-In Fee for Patient Sample Testing, Extra Hours, per hour |
| T4I |
| Call-In Fee for Antigen Negative Requests, Screening Required |
Description Fee
| C5I |
| Import Fee, Rare Product |
| D5I |
| Search fee, Rare Product |
| B6I |
| Hemoglobin S, per test |
| 86850 |
| Antibody Screen, each media |
| 86870 |
| Antibody ID, each panel & media |
| 86886 |
| Indirect Titer, per antibody |
| G5I |
| Antigen Type, not labeled - segment test/report, per antigen, per unit |
| H5I |
| Antigen Screen with Patient Serum, per antigen, per unit |
| 86905 |
| RBC Antigen Other Than ABO/D, each |
| 86906 |
| Rh Phenotyping, complete |
| 86920 |
| Immediate Spin Crossmatch |
| O5I |
| AGT Phase of Crossmatch, includes incubation of crossmatch |
| 86970 |
| Pretreatment of Cells With Chemical Agents or Drugs, per cell |
| 86971 |
| Pretreatment With Enzymes, per cell |
| 86972 |
| Separation by Density Gradient, reticulocytes |
| 86975 |
| Incubation: serum & drugs, each |
| 86976 |
| Dilution of Serum, per aliquot |
| 86977 |
| Incubation with Inhibitors, per aliquot |
| 86978 |
| Differential/Auto Adsorption of Serum, each |
| A4I |
| Red Cell Antigen Negative, 1 antigen per unit |
| B4I |
| Red Cell Antigen Negative, 2 antigens per unit |
| C4I |
| Red Cell Antigen Negative, 3 antigens per unit |
| D4I |
| Red Cell Antigen Negative, 4 antigens per unit |
| E4I |
| Red Cell Antigen Negative, 5 antigens per unit |
| F4I |
| Red Cell Antigen Negative, 6 antigens per unit |
| G4I |
| Red Cell Antigen Negative, 7 antigens per unit |
| H4I |
| Red Cell Antigen Negative, 8 antigens per unit |
| I4I |
| Red Cell Antigen Negative, 9 antigens per unit |
| REF12 |
| Miscellaneous Adsorption, per adsorption |
| REF13 |
| Complex Preparation of Patient Cells for Adsorption |
| REF14 |
| Thawing Rare Reagent Red Cells, per cell |
| REF18 |
| Segment Procurement, per ten segments |
| REF23 |
| NRLBGS Referral Fee, fees dependent upon tests requested |
RBC Antigen Negative, Rare Unit Fee; for each request for units of frequency less than 2% of the population and/or >75 units screened.
Prorated billing for screening of <75 units as follows:
| J4I |
| Antigen screening, 1-10 units |
| K4I |
| Antigen screening, 11-20 units |
| L4I |
| Antigen screening, 21-30 units |
| M4I |
| Antigen screening, 31-40 units |
| N4I |
| Antigen screening, 41-50 units |
| O4I |
| Antigen screening, 51-60 units |
| P4I |
| Antigen screening, 61-74 units |
FEE SCHEDULE, OPTON YEAR TWO
RED BLOOD CELLS, RBC Fee RBC - Leukoreduced RBC - Non-Leukoreduced (autologous only) RBC - Washed RBC - Deglycerolyzed RBC - Divided
WHOLE BLOOD
Whole Blood (autologous only) Whole Blood - Leukoreduced (autologous only)
FROZEN PLASMA
Plasma - Frozen within 24 hours Plasma - Fresh Frozen (limited availability) Plasma - Divided Plasma - Cryo-reduced
CRYOPRECIPITATED ANTI-HEMOPHILIAC FACTOR
Cryoprecipitated-AHF Pooled Cryoprecipitated-AHF (pool of 5)
Plateletpheresis - Leukoreduced
Platelet Additive Solution Plateletpheresis - Leukoreduced
Granulocytes Pheresis
Granulocyte Cancellation After Set Up
| A7I |
| HLA Matched Platelet Surcharge, per unit |
| J5I |
| Platelet Component, Crossmatched |
| 91021 |
| Leukocyte Antibody Identification |
| 91029 |
| Platelet Antibody, each technique |
| HLA009 |
| HLA Antibody Testing by ELISA |
Autologous Surcharge, per unit
Directed Surcharge, per unit
| IRRD |
| Irradiation Surcharge, per unit |
| P1M |
| Four Empty Bags Attached Surcharge, per unit |
Call-In / Stat Fee - applied for services requested after 4:30PM on
| 66128 |
| Call-In Fee for Patient Sample Testing, first 2 hours |
| REF31 |
| Call-In Fee for Patient Sample Testing, Extra Hours, per hour |
| T4I |
| Call-In Fee for Antigen Negative Requests, Screening Required |
Description Fee
| C5I |
| Import Fee, Rare Product |
| D5I |
| Search fee, Rare Product |
| B6I |
| Hemoglobin S, per test |
| 86850 |
| Antibody Screen, each media |
| 86870 |
| Antibody ID, each panel & media |
| 86886 |
| Indirect Titer, per antibody |
| G5I |
| Antigen Type, not labeled - segment test/report, per antigen, per unit |
| H5I |
| Antigen Screen with Patient Serum, per antigen, per unit |
| 86905 |
| RBC Antigen Other Than ABO/D, each |
| 86906 |
| Rh Phenotyping, complete |
| 86920 |
| Immediate Spin Crossmatch |
| O5I |
| AGT Phase of Crossmatch, includes incubation of crossmatch |
| 86970 |
| Pretreatment of Cells With Chemical Agents or Drugs, per cell |
| 86971 |
| Pretreatment With Enzymes, per cell |
| 86972 |
| Separation by Density Gradient, reticulocytes |
| 86975 |
| Incubation: serum & drugs, each |
| 86976 |
| Dilution of Serum, per aliquot |
| 86977 |
| Incubation with Inhibitors, per aliquot |
| 86978 |
| Differential/Auto Adsorption of Serum, each |
| A4I |
| Red Cell Antigen Negative, 1 antigen per unit |
| B4I |
| Red Cell Antigen Negative, 2 antigens per unit |
| C4I |
| Red Cell Antigen Negative, 3 antigens per unit |
| D4I |
| Red Cell Antigen Negative, 4 antigens per unit |
| E4I |
| Red Cell Antigen Negative, 5 antigens per unit |
| F4I |
| Red Cell Antigen Negative, 6 antigens per unit |
| G4I |
| Red Cell Antigen Negative, 7 antigens per unit |
| H4I |
| Red Cell Antigen Negative, 8 antigens per unit |
| I4I |
| Red Cell Antigen Negative, 9 antigens per unit |
| REF12 |
| Miscellaneous Adsorption, per adsorption |
| REF13 |
| Complex Preparation of Patient Cells for Adsorption |
| REF14 |
| Thawing Rare Reagent Red Cells, per cell |
| REF18 |
| Segment Procurement, per ten segments |
| REF23 |
| NRLBGS Referral Fee, fees dependent upon tests requested |
RBC Antigen Negative, Rare Unit Fee; for each request for units of frequency less than 2% of the population and/or >75 units screened.
Prorated billing for screening of <75 units as follows:
| J4I |
| Antigen screening, 1-10 units |
| K4I |
| Antigen screening, 11-20 units |
| L4I |
| Antigen screening, 21-30 units |
| M4I |
| Antigen screening, 31-40 units |
| N4I |
| Antigen screening, 41-50 units |
| O4I |
| Antigen screening, 51-60 units |
| P4I |
| Antigen screening, 61-74 units |
FEE SCHEDULE, OPTION YEAR THREE
RED BLOOD CELLS, RBC Fee RBC - Leukoreduced RBC - Non-Leukoreduced (autologous only) RBC - Washed RBC - Deglycerolyzed RBC - Divided
WHOLE BLOOD
Whole Blood (autologous only) Whole Blood - Leukoreduced (autologous only)
FROZEN PLASMA
Plasma - Frozen within 24 hours Plasma - Fresh Frozen (limited availability) Plasma - Divided Plasma - Cryo-reduced
CRYOPRECIPITATED ANTI-HEMOPHILIAC FACTOR
Cryoprecipitated-AHF Pooled Cryoprecipitated-AHF (pool of 5)
Plateletpheresis - Leukoreduced
Platelet Additive Solution Plateletpheresis - Leukoreduced
Granulocytes Pheresis
Granulocyte Cancellation After Set Up
| A7I |
| HLA Matched Platelet Surcharge, per unit |
| J5I |
| Platelet Component, Crossmatched |
| 91021 |
| Leukocyte Antibody Identification |
| 91029 |
| Platelet Antibody, each technique |
| HLA009 |
| HLA Antibody Testing by ELISA |
Autologous Surcharge, per unit
Directed Surcharge, per unit
| IRRD |
| Irradiation Surcharge, per unit |
| P1M |
| Four Empty Bags Attached Surcharge, per unit |
Call-In / Stat Fee - applied for services requested after 4:30PM on
| 66128 |
| Call-In Fee for Patient Sample Testing, first 2 hours |
| REF31 |
| Call-In Fee for Patient Sample Testing, Extra Hours, per hour |
| T4I |
| Call-In Fee for Antigen Negative Requests, Screening Required |
Description Fee
| C5I |
| Import Fee, Rare Product |
| D5I |
| Search fee, Rare Product |
| B6I |
| Hemoglobin S, per test |
| 86850 |
| Antibody Screen, each media |
| 86870 |
| Antibody ID, each panel & media |
| 86886 |
| Indirect Titer, per antibody |
| G5I |
| Antigen Type, not labeled - segment test/report, per antigen, per unit |
| H5I |
| Antigen Screen with Patient Serum, per antigen, per unit |
| 86905 |
| RBC Antigen Other Than ABO/D, each |
| 86906 |
| Rh Phenotyping, complete |
| 86920 |
| Immediate Spin Crossmatch |
| O5I |
| AGT Phase of Crossmatch, includes incubation of crossmatch |
| 86970 |
| Pretreatment of Cells With Chemical Agents or Drugs, per cell |
| 86971 |
| Pretreatment With Enzymes, per cell |
| 86972 |
| Separation by Density Gradient, reticulocytes |
| 86975 |
| Incubation: serum & drugs, each |
| 86976 |
| Dilution of Serum, per aliquot |
| 86977 |
| Incubation with Inhibitors, per aliquot |
| 86978 |
| Differential/Auto Adsorption of Serum, each |
| A4I |
| Red Cell Antigen Negative, 1 antigen per unit |
| B4I |
| Red Cell Antigen Negative, 2 antigens per unit |
| C4I |
| Red Cell Antigen Negative, 3 antigens per unit |
| D4I |
| Red Cell Antigen Negative, 4 antigens per unit |
| E4I |
| Red Cell Antigen Negative, 5 antigens per unit |
| F4I |
| Red Cell Antigen Negative, 6 antigens per unit |
| G4I |
| Red Cell Antigen Negative, 7 antigens per unit |
| H4I |
| Red Cell Antigen Negative, 8 antigens per unit |
| I4I |
| Red Cell Antigen Negative, 9 antigens per unit |
| REF12 |
| Miscellaneous Adsorption, per adsorption |
| REF13 |
| Complex Preparation of Patient Cells for Adsorption |
| REF14 |
| Thawing Rare Reagent Red Cells, per cell |
| REF18 |
| Segment Procurement, per ten segments |
| REF23 |
| NRLBGS Referral Fee, fees dependent upon tests requested |
RBC Antigen Negative, Rare Unit Fee; for each request for units of frequency less than 2% of the population and/or >75 units screened.
Prorated billing for screening of <75 units as follows:
| J4I |
| Antigen screening, 1-10 units |
| K4I |
| Antigen screening, 11-20 units |
| L4I |
| Antigen screening, 21-30 units |
| M4I |
| Antigen screening, 31-40 units |
| N4I |
| Antigen screening, 41-50 units |
| O4I |
| Antigen screening, 51-60 units |
| P4I |
| Antigen screening, 61-74 units |
FEE SCHEDULE, OPTION YEAR FOUR
RED BLOOD CELLS, RBC Fee RBC - Leukoreduced RBC - Non-Leukoreduced (autologous only) RBC - Washed RBC - Deglycerolyzed RBC - Divided
WHOLE BLOOD
Whole Blood (autologous only) Whole Blood - Leukoreduced (autologous only)
FROZEN PLASMA
Plasma - Frozen within 24 hours Plasma - Fresh Frozen (limited availability) Plasma - Divided Plasma - Cryo-reduced
CRYOPRECIPITATED ANTI-HEMOPHILIAC FACTOR
Cryoprecipitated-AHF Pooled Cryoprecipitated-AHF (pool of 5)
Plateletpheresis - Leukoreduced
Platelet Additive Solution Plateletpheresis - Leukoreduced
Granulocytes Pheresis
Granulocyte Cancellation After Set Up
| A7I |
| HLA Matched Platelet Surcharge, per unit |
| J5I |
| Platelet Component, Crossmatched |
| 91021 |
| Leukocyte Antibody Identification |
| 91029 |
| Platelet Antibody, each technique |
| HLA009 |
| HLA Antibody Testing by ELISA |
Autologous Surcharge, per unit
Directed Surcharge, per unit
| IRRD |
| Irradiation Surcharge, per unit |
| P1M |
| Four Empty Bags Attached Surcharge, per unit |
Call-In / Stat Fee - applied for services requested after 4:30PM on
| 66128 |
| Call-In Fee for Patient Sample Testing, first 2 hours |
| REF31 |
| Call-In Fee for Patient Sample Testing, Extra Hours, per hour |
| T4I |
| Call-In Fee for Antigen Negative Requests, Screening Required |
Description Fee
| C5I |
| Import Fee, Rare Product |
| D5I |
| Search fee, Rare Product |
| B6I |
| Hemoglobin S, per test |
| 86850 |
| Antibody Screen, each media |
| 86870 |
| Antibody ID, each panel & media |
| 86886 |
| Indirect Titer, per antibody |
| G5I |
| Antigen Type, not labeled - segment test/report, per antigen, per unit |
| H5I |
| Antigen Screen with Patient Serum, per antigen, per unit |
| 86905 |
| RBC Antigen Other Than ABO/D, each |
| 86906 |
| Rh Phenotyping, complete |
| 86920 |
| Immediate Spin Crossmatch |
| O5I |
| AGT Phase of Crossmatch, includes incubation of crossmatch |
| 86970 |
| Pretreatment of Cells With Chemical Agents or Drugs, per cell |
| 86971 |
| Pretreatment With Enzymes, per cell |
| 86972 |
| Separation by Density Gradient, reticulocytes |
| 86975 |
| Incubation: serum & drugs, each |
| 86976 |
| Dilution of Serum, per aliquot |
| 86977 |
| Incubation with Inhibitors, per aliquot |
| 86978 |
| Differential/Auto Adsorption of Serum, each |
| A4I |
| Red Cell Antigen Negative, 1 antigen per unit |
| B4I |
| Red Cell Antigen Negative, 2 antigens per unit |
| C4I |
| Red Cell Antigen Negative, 3 antigens per unit |
| D4I |
| Red Cell Antigen Negative, 4 antigens per unit |
| E4I |
| Red Cell Antigen Negative, 5 antigens per unit |
| F4I |
| Red Cell Antigen Negative, 6 antigens per unit |
| G4I |
| Red Cell Antigen Negative, 7 antigens per unit |
| H4I |
| Red Cell Antigen Negative, 8 antigens per unit |
| I4I |
| Red Cell Antigen Negative, 9 antigens per unit |
| REF12 |
| Miscellaneous Adsorption, per adsorption |
| REF13 |
| Complex Preparation of Patient Cells for Adsorption |
| REF14 |
| Thawing Rare Reagent Red Cells, per cell |
| REF18 |
| Segment Procurement, per ten segments |
| REF23 |
| NRLBGS Referral Fee, fees dependent upon tests requested |
RBC Antigen Negative, Rare Unit Fee; for each request for units of frequency less than 2% of the population and/or >75 units screened.
Prorated billing for screening of <75 units as follows:
| J4I |
| Antigen screening, 1-10 units |
| K4I |
| Antigen screening, 11-20 units |
| L4I |
| Antigen screening, 21-30 units |
| M4I |
| Antigen screening, 31-40 units |
| N4I |
| Antigen screening, 41-50 units |
| O4I |
| Antigen screening, 51-60 units |
| P4I |
| Antigen screening, 61-74 units |
