|
ANKLE SPLINT LACE-UP LG
|
Facility
|
IP
|
$36.00
|
|
|
Service Code
|
HCPCS E1815
|
| Hospital Charge Code |
2893174
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$25.20 |
| Max. Negotiated Rate |
$36.00 |
| Rate for Payer: Aetna Commercial |
$34.20
|
| Rate for Payer: Aetna Medicare |
$32.40
|
| Rate for Payer: BCBS MT CHIP |
$32.40
|
| Rate for Payer: BCBS MT Closed Plan Network |
$34.20
|
| Rate for Payer: BCBS MT HealthLink |
$32.40
|
| Rate for Payer: BCBS MT Medicare |
$32.40
|
| Rate for Payer: BCBS MT POS |
$34.20
|
| Rate for Payer: BCBS MT Traditional |
$36.00
|
| Rate for Payer: Cash Price |
$32.40
|
| Rate for Payer: Cigna Commercial |
$34.20
|
| Rate for Payer: Cigna Medicare |
$32.40
|
| Rate for Payer: Medicaid All Medicaid |
$33.12
|
| Rate for Payer: Medicare All Medicare |
$25.20
|
| Rate for Payer: Monida Allegiance |
$34.20
|
| Rate for Payer: Monida First Choice Health |
$34.92
|
| Rate for Payer: Monida Montana Health Co-op |
$34.20
|
| Rate for Payer: Monida PacificSource |
$34.20
|
|
|
ANKLE SPLINT LACE-UP MED
|
Facility
|
IP
|
$36.00
|
|
|
Service Code
|
HCPCS E1815
|
| Hospital Charge Code |
2893173
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$25.20 |
| Max. Negotiated Rate |
$36.00 |
| Rate for Payer: Aetna Commercial |
$34.20
|
| Rate for Payer: Aetna Medicare |
$32.40
|
| Rate for Payer: BCBS MT CHIP |
$32.40
|
| Rate for Payer: BCBS MT Closed Plan Network |
$34.20
|
| Rate for Payer: BCBS MT HealthLink |
$32.40
|
| Rate for Payer: BCBS MT Medicare |
$32.40
|
| Rate for Payer: BCBS MT POS |
$34.20
|
| Rate for Payer: BCBS MT Traditional |
$36.00
|
| Rate for Payer: Cash Price |
$32.40
|
| Rate for Payer: Cigna Commercial |
$34.20
|
| Rate for Payer: Cigna Medicare |
$32.40
|
| Rate for Payer: Medicaid All Medicaid |
$33.12
|
| Rate for Payer: Medicare All Medicare |
$25.20
|
| Rate for Payer: Monida Allegiance |
$34.20
|
| Rate for Payer: Monida First Choice Health |
$34.92
|
| Rate for Payer: Monida Montana Health Co-op |
$34.20
|
| Rate for Payer: Monida PacificSource |
$34.20
|
|
|
ANKLE SPLINT LACE-UP MED
|
Facility
|
OP
|
$36.00
|
|
|
Service Code
|
HCPCS E1815
|
| Hospital Charge Code |
2893173
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$25.20 |
| Max. Negotiated Rate |
$36.00 |
| Rate for Payer: Aetna Commercial |
$34.20
|
| Rate for Payer: Aetna Medicare |
$32.40
|
| Rate for Payer: BCBS MT CHIP |
$32.40
|
| Rate for Payer: BCBS MT Closed Plan Network |
$34.20
|
| Rate for Payer: BCBS MT HealthLink |
$32.40
|
| Rate for Payer: BCBS MT Medicare |
$32.40
|
| Rate for Payer: BCBS MT POS |
$34.20
|
| Rate for Payer: BCBS MT Traditional |
$36.00
|
| Rate for Payer: Cash Price |
$32.40
|
| Rate for Payer: Cigna Commercial |
$34.20
|
| Rate for Payer: Cigna Medicare |
$32.40
|
| Rate for Payer: Medicaid All Medicaid |
$33.12
|
| Rate for Payer: Medicare All Medicare |
$25.20
|
| Rate for Payer: Monida Allegiance |
$34.20
|
| Rate for Payer: Monida First Choice Health |
$34.92
|
| Rate for Payer: Monida Montana Health Co-op |
$34.20
|
| Rate for Payer: Monida PacificSource |
$34.20
|
|
|
ANKLE SUPPORT
|
Facility
|
OP
|
$159.00
|
|
|
Service Code
|
HCPCS L1902
|
| Hospital Charge Code |
8001902
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$111.30 |
| Max. Negotiated Rate |
$159.00 |
| Rate for Payer: Aetna Commercial |
$151.05
|
| Rate for Payer: Aetna Medicare |
$143.10
|
| Rate for Payer: BCBS MT CHIP |
$143.10
|
| Rate for Payer: BCBS MT Closed Plan Network |
$151.05
|
| Rate for Payer: BCBS MT HealthLink |
$143.10
|
| Rate for Payer: BCBS MT Medicare |
$143.10
|
| Rate for Payer: BCBS MT POS |
$151.05
|
| Rate for Payer: BCBS MT Traditional |
$159.00
|
| Rate for Payer: Cash Price |
$143.10
|
| Rate for Payer: Cigna Commercial |
$151.05
|
| Rate for Payer: Cigna Medicare |
$143.10
|
| Rate for Payer: Medicaid All Medicaid |
$146.28
|
| Rate for Payer: Medicare All Medicare |
$111.30
|
| Rate for Payer: Monida Allegiance |
$151.05
|
| Rate for Payer: Monida First Choice Health |
$154.23
|
| Rate for Payer: Monida Montana Health Co-op |
$151.05
|
| Rate for Payer: Monida PacificSource |
$151.05
|
|
|
ANKLE SUPPORT
|
Facility
|
IP
|
$159.00
|
|
|
Service Code
|
HCPCS L1902
|
| Hospital Charge Code |
8001902
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$111.30 |
| Max. Negotiated Rate |
$159.00 |
| Rate for Payer: Aetna Commercial |
$151.05
|
| Rate for Payer: Aetna Medicare |
$143.10
|
| Rate for Payer: BCBS MT CHIP |
$143.10
|
| Rate for Payer: BCBS MT Closed Plan Network |
$151.05
|
| Rate for Payer: BCBS MT HealthLink |
$143.10
|
| Rate for Payer: BCBS MT Medicare |
$143.10
|
| Rate for Payer: BCBS MT POS |
$151.05
|
| Rate for Payer: BCBS MT Traditional |
$159.00
|
| Rate for Payer: Cash Price |
$143.10
|
| Rate for Payer: Cigna Commercial |
$151.05
|
| Rate for Payer: Cigna Medicare |
$143.10
|
| Rate for Payer: Medicaid All Medicaid |
$146.28
|
| Rate for Payer: Medicare All Medicare |
$111.30
|
| Rate for Payer: Monida Allegiance |
$151.05
|
| Rate for Payer: Monida First Choice Health |
$154.23
|
| Rate for Payer: Monida Montana Health Co-op |
$151.05
|
| Rate for Payer: Monida PacificSource |
$151.05
|
|
|
ANKLE SUPPORT CRISCROS LG
|
Facility
|
IP
|
$51.00
|
|
| Hospital Charge Code |
2893177
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$35.70 |
| Max. Negotiated Rate |
$51.00 |
| Rate for Payer: Aetna Commercial |
$48.45
|
| Rate for Payer: Aetna Medicare |
$45.90
|
| Rate for Payer: BCBS MT CHIP |
$45.90
|
| Rate for Payer: BCBS MT Closed Plan Network |
$48.45
|
| Rate for Payer: BCBS MT HealthLink |
$45.90
|
| Rate for Payer: BCBS MT Medicare |
$45.90
|
| Rate for Payer: BCBS MT POS |
$48.45
|
| Rate for Payer: BCBS MT Traditional |
$51.00
|
| Rate for Payer: Cash Price |
$45.90
|
| Rate for Payer: Cigna Commercial |
$48.45
|
| Rate for Payer: Cigna Medicare |
$45.90
|
| Rate for Payer: Medicaid All Medicaid |
$46.92
|
| Rate for Payer: Medicare All Medicare |
$35.70
|
| Rate for Payer: Monida Allegiance |
$48.45
|
| Rate for Payer: Monida First Choice Health |
$49.47
|
| Rate for Payer: Monida Montana Health Co-op |
$48.45
|
| Rate for Payer: Monida PacificSource |
$48.45
|
|
|
ANKLE SUPPORT CRISCROS LG
|
Facility
|
OP
|
$51.00
|
|
| Hospital Charge Code |
2893177
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$35.70 |
| Max. Negotiated Rate |
$51.00 |
| Rate for Payer: Aetna Commercial |
$48.45
|
| Rate for Payer: Aetna Medicare |
$45.90
|
| Rate for Payer: BCBS MT CHIP |
$45.90
|
| Rate for Payer: BCBS MT Closed Plan Network |
$48.45
|
| Rate for Payer: BCBS MT HealthLink |
$45.90
|
| Rate for Payer: BCBS MT Medicare |
$45.90
|
| Rate for Payer: BCBS MT POS |
$48.45
|
| Rate for Payer: BCBS MT Traditional |
$51.00
|
| Rate for Payer: Cash Price |
$45.90
|
| Rate for Payer: Cigna Commercial |
$48.45
|
| Rate for Payer: Cigna Medicare |
$45.90
|
| Rate for Payer: Medicaid All Medicaid |
$46.92
|
| Rate for Payer: Medicare All Medicare |
$35.70
|
| Rate for Payer: Monida Allegiance |
$48.45
|
| Rate for Payer: Monida First Choice Health |
$49.47
|
| Rate for Payer: Monida Montana Health Co-op |
$48.45
|
| Rate for Payer: Monida PacificSource |
$48.45
|
|
|
ANKLE SUPPORT CRISCROS MED
|
Facility
|
IP
|
$51.00
|
|
| Hospital Charge Code |
2893176
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$35.70 |
| Max. Negotiated Rate |
$51.00 |
| Rate for Payer: Aetna Commercial |
$48.45
|
| Rate for Payer: Aetna Medicare |
$45.90
|
| Rate for Payer: BCBS MT CHIP |
$45.90
|
| Rate for Payer: BCBS MT Closed Plan Network |
$48.45
|
| Rate for Payer: BCBS MT HealthLink |
$45.90
|
| Rate for Payer: BCBS MT Medicare |
$45.90
|
| Rate for Payer: BCBS MT POS |
$48.45
|
| Rate for Payer: BCBS MT Traditional |
$51.00
|
| Rate for Payer: Cash Price |
$45.90
|
| Rate for Payer: Cigna Commercial |
$48.45
|
| Rate for Payer: Cigna Medicare |
$45.90
|
| Rate for Payer: Medicaid All Medicaid |
$46.92
|
| Rate for Payer: Medicare All Medicare |
$35.70
|
| Rate for Payer: Monida Allegiance |
$48.45
|
| Rate for Payer: Monida First Choice Health |
$49.47
|
| Rate for Payer: Monida Montana Health Co-op |
$48.45
|
| Rate for Payer: Monida PacificSource |
$48.45
|
|
|
ANKLE SUPPORT CRISCROS MED
|
Facility
|
OP
|
$51.00
|
|
| Hospital Charge Code |
2893176
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$35.70 |
| Max. Negotiated Rate |
$51.00 |
| Rate for Payer: Aetna Commercial |
$48.45
|
| Rate for Payer: Aetna Medicare |
$45.90
|
| Rate for Payer: BCBS MT CHIP |
$45.90
|
| Rate for Payer: BCBS MT Closed Plan Network |
$48.45
|
| Rate for Payer: BCBS MT HealthLink |
$45.90
|
| Rate for Payer: BCBS MT Medicare |
$45.90
|
| Rate for Payer: BCBS MT POS |
$48.45
|
| Rate for Payer: BCBS MT Traditional |
$51.00
|
| Rate for Payer: Cash Price |
$45.90
|
| Rate for Payer: Cigna Commercial |
$48.45
|
| Rate for Payer: Cigna Medicare |
$45.90
|
| Rate for Payer: Medicaid All Medicaid |
$46.92
|
| Rate for Payer: Medicare All Medicare |
$35.70
|
| Rate for Payer: Monida Allegiance |
$48.45
|
| Rate for Payer: Monida First Choice Health |
$49.47
|
| Rate for Payer: Monida Montana Health Co-op |
$48.45
|
| Rate for Payer: Monida PacificSource |
$48.45
|
|
|
ANKLE SUPPORT CRISCROS SM
|
Facility
|
OP
|
$64.00
|
|
| Hospital Charge Code |
2840087
|
|
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 MT CHIP |
$57.60
|
| Rate for Payer: BCBS MT Closed Plan Network |
$60.80
|
| Rate for Payer: BCBS MT HealthLink |
$57.60
|
| Rate for Payer: BCBS MT Medicare |
$57.60
|
| Rate for Payer: BCBS MT POS |
$60.80
|
| Rate for Payer: BCBS MT Traditional |
$64.00
|
| Rate for Payer: Cash Price |
$57.60
|
| Rate for Payer: Cigna Commercial |
$60.80
|
| Rate for Payer: Cigna Medicare |
$57.60
|
| Rate for Payer: Medicaid All Medicaid |
$58.88
|
| Rate for Payer: Medicare All Medicare |
$44.80
|
| Rate for Payer: Monida Allegiance |
$60.80
|
| Rate for Payer: Monida First Choice Health |
$62.08
|
| Rate for Payer: Monida Montana Health Co-op |
$60.80
|
| Rate for Payer: Monida PacificSource |
$60.80
|
|
|
ANKLE SUPPORT CRISCROS SM
|
Facility
|
IP
|
$64.00
|
|
| Hospital Charge Code |
2840087
|
|
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 MT CHIP |
$57.60
|
| Rate for Payer: BCBS MT Closed Plan Network |
$60.80
|
| Rate for Payer: BCBS MT HealthLink |
$57.60
|
| Rate for Payer: BCBS MT Medicare |
$57.60
|
| Rate for Payer: BCBS MT POS |
$60.80
|
| Rate for Payer: BCBS MT Traditional |
$64.00
|
| Rate for Payer: Cash Price |
$57.60
|
| Rate for Payer: Cigna Commercial |
$60.80
|
| Rate for Payer: Cigna Medicare |
$57.60
|
| Rate for Payer: Medicaid All Medicaid |
$58.88
|
| Rate for Payer: Medicare All Medicare |
$44.80
|
| Rate for Payer: Monida Allegiance |
$60.80
|
| Rate for Payer: Monida First Choice Health |
$62.08
|
| Rate for Payer: Monida Montana Health Co-op |
$60.80
|
| Rate for Payer: Monida PacificSource |
$60.80
|
|
|
ANKLE SUPPORT CRISCROS XLG
|
Facility
|
IP
|
$51.00
|
|
| Hospital Charge Code |
2893178
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$35.70 |
| Max. Negotiated Rate |
$51.00 |
| Rate for Payer: Aetna Commercial |
$48.45
|
| Rate for Payer: Aetna Medicare |
$45.90
|
| Rate for Payer: BCBS MT CHIP |
$45.90
|
| Rate for Payer: BCBS MT Closed Plan Network |
$48.45
|
| Rate for Payer: BCBS MT HealthLink |
$45.90
|
| Rate for Payer: BCBS MT Medicare |
$45.90
|
| Rate for Payer: BCBS MT POS |
$48.45
|
| Rate for Payer: BCBS MT Traditional |
$51.00
|
| Rate for Payer: Cash Price |
$45.90
|
| Rate for Payer: Cigna Commercial |
$48.45
|
| Rate for Payer: Cigna Medicare |
$45.90
|
| Rate for Payer: Medicaid All Medicaid |
$46.92
|
| Rate for Payer: Medicare All Medicare |
$35.70
|
| Rate for Payer: Monida Allegiance |
$48.45
|
| Rate for Payer: Monida First Choice Health |
$49.47
|
| Rate for Payer: Monida Montana Health Co-op |
$48.45
|
| Rate for Payer: Monida PacificSource |
$48.45
|
|
|
ANKLE SUPPORT CRISCROS XLG
|
Facility
|
OP
|
$51.00
|
|
| Hospital Charge Code |
2893178
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$35.70 |
| Max. Negotiated Rate |
$51.00 |
| Rate for Payer: Aetna Commercial |
$48.45
|
| Rate for Payer: Aetna Medicare |
$45.90
|
| Rate for Payer: BCBS MT CHIP |
$45.90
|
| Rate for Payer: BCBS MT Closed Plan Network |
$48.45
|
| Rate for Payer: BCBS MT HealthLink |
$45.90
|
| Rate for Payer: BCBS MT Medicare |
$45.90
|
| Rate for Payer: BCBS MT POS |
$48.45
|
| Rate for Payer: BCBS MT Traditional |
$51.00
|
| Rate for Payer: Cash Price |
$45.90
|
| Rate for Payer: Cigna Commercial |
$48.45
|
| Rate for Payer: Cigna Medicare |
$45.90
|
| Rate for Payer: Medicaid All Medicaid |
$46.92
|
| Rate for Payer: Medicare All Medicare |
$35.70
|
| Rate for Payer: Monida Allegiance |
$48.45
|
| Rate for Payer: Monida First Choice Health |
$49.47
|
| Rate for Payer: Monida Montana Health Co-op |
$48.45
|
| Rate for Payer: Monida PacificSource |
$48.45
|
|
|
ANKLE SUPPORT LG ELASTIC
|
Facility
|
IP
|
$11.00
|
|
| Hospital Charge Code |
2893181
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$7.70 |
| Max. Negotiated Rate |
$11.00 |
| Rate for Payer: Aetna Commercial |
$10.45
|
| Rate for Payer: Aetna Medicare |
$9.90
|
| Rate for Payer: BCBS MT CHIP |
$9.90
|
| Rate for Payer: BCBS MT Closed Plan Network |
$10.45
|
| Rate for Payer: BCBS MT HealthLink |
$9.90
|
| Rate for Payer: BCBS MT Medicare |
$9.90
|
| Rate for Payer: BCBS MT POS |
$10.45
|
| Rate for Payer: BCBS MT Traditional |
$11.00
|
| Rate for Payer: Cash Price |
$9.90
|
| Rate for Payer: Cigna Commercial |
$10.45
|
| Rate for Payer: Cigna Medicare |
$9.90
|
| Rate for Payer: Medicaid All Medicaid |
$10.12
|
| Rate for Payer: Medicare All Medicare |
$7.70
|
| Rate for Payer: Monida Allegiance |
$10.45
|
| Rate for Payer: Monida First Choice Health |
$10.67
|
| Rate for Payer: Monida Montana Health Co-op |
$10.45
|
| Rate for Payer: Monida PacificSource |
$10.45
|
|
|
ANKLE SUPPORT LG ELASTIC
|
Facility
|
OP
|
$11.00
|
|
| Hospital Charge Code |
2893181
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$7.70 |
| Max. Negotiated Rate |
$11.00 |
| Rate for Payer: Aetna Commercial |
$10.45
|
| Rate for Payer: Aetna Medicare |
$9.90
|
| Rate for Payer: BCBS MT CHIP |
$9.90
|
| Rate for Payer: BCBS MT Closed Plan Network |
$10.45
|
| Rate for Payer: BCBS MT HealthLink |
$9.90
|
| Rate for Payer: BCBS MT Medicare |
$9.90
|
| Rate for Payer: BCBS MT POS |
$10.45
|
| Rate for Payer: BCBS MT Traditional |
$11.00
|
| Rate for Payer: Cash Price |
$9.90
|
| Rate for Payer: Cigna Commercial |
$10.45
|
| Rate for Payer: Cigna Medicare |
$9.90
|
| Rate for Payer: Medicaid All Medicaid |
$10.12
|
| Rate for Payer: Medicare All Medicare |
$7.70
|
| Rate for Payer: Monida Allegiance |
$10.45
|
| Rate for Payer: Monida First Choice Health |
$10.67
|
| Rate for Payer: Monida Montana Health Co-op |
$10.45
|
| Rate for Payer: Monida PacificSource |
$10.45
|
|
|
ANKLE SUPPORT MD ELASTIC
|
Facility
|
OP
|
$11.00
|
|
| Hospital Charge Code |
2893180
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$7.70 |
| Max. Negotiated Rate |
$11.00 |
| Rate for Payer: Aetna Commercial |
$10.45
|
| Rate for Payer: Aetna Medicare |
$9.90
|
| Rate for Payer: BCBS MT CHIP |
$9.90
|
| Rate for Payer: BCBS MT Closed Plan Network |
$10.45
|
| Rate for Payer: BCBS MT HealthLink |
$9.90
|
| Rate for Payer: BCBS MT Medicare |
$9.90
|
| Rate for Payer: BCBS MT POS |
$10.45
|
| Rate for Payer: BCBS MT Traditional |
$11.00
|
| Rate for Payer: Cash Price |
$9.90
|
| Rate for Payer: Cigna Commercial |
$10.45
|
| Rate for Payer: Cigna Medicare |
$9.90
|
| Rate for Payer: Medicaid All Medicaid |
$10.12
|
| Rate for Payer: Medicare All Medicare |
$7.70
|
| Rate for Payer: Monida Allegiance |
$10.45
|
| Rate for Payer: Monida First Choice Health |
$10.67
|
| Rate for Payer: Monida Montana Health Co-op |
$10.45
|
| Rate for Payer: Monida PacificSource |
$10.45
|
|
|
ANKLE SUPPORT MD ELASTIC
|
Facility
|
IP
|
$11.00
|
|
| Hospital Charge Code |
2893180
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$7.70 |
| Max. Negotiated Rate |
$11.00 |
| Rate for Payer: Aetna Commercial |
$10.45
|
| Rate for Payer: Aetna Medicare |
$9.90
|
| Rate for Payer: BCBS MT CHIP |
$9.90
|
| Rate for Payer: BCBS MT Closed Plan Network |
$10.45
|
| Rate for Payer: BCBS MT HealthLink |
$9.90
|
| Rate for Payer: BCBS MT Medicare |
$9.90
|
| Rate for Payer: BCBS MT POS |
$10.45
|
| Rate for Payer: BCBS MT Traditional |
$11.00
|
| Rate for Payer: Cash Price |
$9.90
|
| Rate for Payer: Cigna Commercial |
$10.45
|
| Rate for Payer: Cigna Medicare |
$9.90
|
| Rate for Payer: Medicaid All Medicaid |
$10.12
|
| Rate for Payer: Medicare All Medicare |
$7.70
|
| Rate for Payer: Monida Allegiance |
$10.45
|
| Rate for Payer: Monida First Choice Health |
$10.67
|
| Rate for Payer: Monida Montana Health Co-op |
$10.45
|
| Rate for Payer: Monida PacificSource |
$10.45
|
|
|
ANKLE SUPPORT SM ELASTIC
|
Facility
|
IP
|
$13.00
|
|
| Hospital Charge Code |
2840174
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$9.10 |
| Max. Negotiated Rate |
$13.00 |
| Rate for Payer: Aetna Commercial |
$12.35
|
| Rate for Payer: Aetna Medicare |
$11.70
|
| Rate for Payer: BCBS MT CHIP |
$11.70
|
| Rate for Payer: BCBS MT Closed Plan Network |
$12.35
|
| Rate for Payer: BCBS MT HealthLink |
$11.70
|
| Rate for Payer: BCBS MT Medicare |
$11.70
|
| Rate for Payer: BCBS MT POS |
$12.35
|
| Rate for Payer: BCBS MT Traditional |
$13.00
|
| Rate for Payer: Cash Price |
$11.70
|
| Rate for Payer: Cigna Commercial |
$12.35
|
| Rate for Payer: Cigna Medicare |
$11.70
|
| Rate for Payer: Medicaid All Medicaid |
$11.96
|
| Rate for Payer: Medicare All Medicare |
$9.10
|
| Rate for Payer: Monida Allegiance |
$12.35
|
| Rate for Payer: Monida First Choice Health |
$12.61
|
| Rate for Payer: Monida Montana Health Co-op |
$12.35
|
| Rate for Payer: Monida PacificSource |
$12.35
|
|
|
ANKLE SUPPORT SM ELASTIC
|
Facility
|
OP
|
$13.00
|
|
| Hospital Charge Code |
2840174
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$9.10 |
| Max. Negotiated Rate |
$13.00 |
| Rate for Payer: Aetna Commercial |
$12.35
|
| Rate for Payer: Aetna Medicare |
$11.70
|
| Rate for Payer: BCBS MT CHIP |
$11.70
|
| Rate for Payer: BCBS MT Closed Plan Network |
$12.35
|
| Rate for Payer: BCBS MT HealthLink |
$11.70
|
| Rate for Payer: BCBS MT Medicare |
$11.70
|
| Rate for Payer: BCBS MT POS |
$12.35
|
| Rate for Payer: BCBS MT Traditional |
$13.00
|
| Rate for Payer: Cash Price |
$11.70
|
| Rate for Payer: Cigna Commercial |
$12.35
|
| Rate for Payer: Cigna Medicare |
$11.70
|
| Rate for Payer: Medicaid All Medicaid |
$11.96
|
| Rate for Payer: Medicare All Medicare |
$9.10
|
| Rate for Payer: Monida Allegiance |
$12.35
|
| Rate for Payer: Monida First Choice Health |
$12.61
|
| Rate for Payer: Monida Montana Health Co-op |
$12.35
|
| Rate for Payer: Monida PacificSource |
$12.35
|
|
|
ANKLE SUPPORT XL ELASTIC
|
Facility
|
OP
|
$11.00
|
|
| Hospital Charge Code |
2893182
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$7.70 |
| Max. Negotiated Rate |
$11.00 |
| Rate for Payer: Aetna Commercial |
$10.45
|
| Rate for Payer: Aetna Medicare |
$9.90
|
| Rate for Payer: BCBS MT CHIP |
$9.90
|
| Rate for Payer: BCBS MT Closed Plan Network |
$10.45
|
| Rate for Payer: BCBS MT HealthLink |
$9.90
|
| Rate for Payer: BCBS MT Medicare |
$9.90
|
| Rate for Payer: BCBS MT POS |
$10.45
|
| Rate for Payer: BCBS MT Traditional |
$11.00
|
| Rate for Payer: Cash Price |
$9.90
|
| Rate for Payer: Cigna Commercial |
$10.45
|
| Rate for Payer: Cigna Medicare |
$9.90
|
| Rate for Payer: Medicaid All Medicaid |
$10.12
|
| Rate for Payer: Medicare All Medicare |
$7.70
|
| Rate for Payer: Monida Allegiance |
$10.45
|
| Rate for Payer: Monida First Choice Health |
$10.67
|
| Rate for Payer: Monida Montana Health Co-op |
$10.45
|
| Rate for Payer: Monida PacificSource |
$10.45
|
|
|
ANKLE SUPPORT XL ELASTIC
|
Facility
|
IP
|
$11.00
|
|
| Hospital Charge Code |
2893182
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$7.70 |
| Max. Negotiated Rate |
$11.00 |
| Rate for Payer: Aetna Commercial |
$10.45
|
| Rate for Payer: Aetna Medicare |
$9.90
|
| Rate for Payer: BCBS MT CHIP |
$9.90
|
| Rate for Payer: BCBS MT Closed Plan Network |
$10.45
|
| Rate for Payer: BCBS MT HealthLink |
$9.90
|
| Rate for Payer: BCBS MT Medicare |
$9.90
|
| Rate for Payer: BCBS MT POS |
$10.45
|
| Rate for Payer: BCBS MT Traditional |
$11.00
|
| Rate for Payer: Cash Price |
$9.90
|
| Rate for Payer: Cigna Commercial |
$10.45
|
| Rate for Payer: Cigna Medicare |
$9.90
|
| Rate for Payer: Medicaid All Medicaid |
$10.12
|
| Rate for Payer: Medicare All Medicare |
$7.70
|
| Rate for Payer: Monida Allegiance |
$10.45
|
| Rate for Payer: Monida First Choice Health |
$10.67
|
| Rate for Payer: Monida Montana Health Co-op |
$10.45
|
| Rate for Payer: Monida PacificSource |
$10.45
|
|
|
ANTIBODY SCREEN
|
Facility
|
IP
|
$147.00
|
|
|
Service Code
|
HCPCS 86850
|
| Hospital Charge Code |
4086850
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$102.90 |
| Max. Negotiated Rate |
$147.00 |
| Rate for Payer: Aetna Commercial |
$139.65
|
| Rate for Payer: Aetna Medicare |
$132.30
|
| Rate for Payer: BCBS MT CHIP |
$132.30
|
| Rate for Payer: BCBS MT Closed Plan Network |
$139.65
|
| Rate for Payer: BCBS MT HealthLink |
$132.30
|
| Rate for Payer: BCBS MT Medicare |
$132.30
|
| Rate for Payer: BCBS MT POS |
$139.65
|
| Rate for Payer: BCBS MT Traditional |
$147.00
|
| Rate for Payer: Cash Price |
$132.30
|
| Rate for Payer: Cigna Commercial |
$139.65
|
| Rate for Payer: Cigna Medicare |
$132.30
|
| Rate for Payer: Medicaid All Medicaid |
$135.24
|
| Rate for Payer: Medicare All Medicare |
$102.90
|
| Rate for Payer: Monida Allegiance |
$139.65
|
| Rate for Payer: Monida First Choice Health |
$142.59
|
| Rate for Payer: Monida Montana Health Co-op |
$139.65
|
| Rate for Payer: Monida PacificSource |
$139.65
|
|
|
ANTIBODY SCREEN
|
Facility
|
OP
|
$147.00
|
|
|
Service Code
|
HCPCS 86850
|
| Hospital Charge Code |
4086850
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$102.90 |
| Max. Negotiated Rate |
$147.00 |
| Rate for Payer: Aetna Commercial |
$139.65
|
| Rate for Payer: Aetna Medicare |
$132.30
|
| Rate for Payer: BCBS MT CHIP |
$132.30
|
| Rate for Payer: BCBS MT Closed Plan Network |
$139.65
|
| Rate for Payer: BCBS MT HealthLink |
$132.30
|
| Rate for Payer: BCBS MT Medicare |
$132.30
|
| Rate for Payer: BCBS MT POS |
$139.65
|
| Rate for Payer: BCBS MT Traditional |
$147.00
|
| Rate for Payer: Cash Price |
$132.30
|
| Rate for Payer: Cigna Commercial |
$139.65
|
| Rate for Payer: Cigna Medicare |
$132.30
|
| Rate for Payer: Medicaid All Medicaid |
$135.24
|
| Rate for Payer: Medicare All Medicare |
$102.90
|
| Rate for Payer: Monida Allegiance |
$139.65
|
| Rate for Payer: Monida First Choice Health |
$142.59
|
| Rate for Payer: Monida Montana Health Co-op |
$139.65
|
| Rate for Payer: Monida PacificSource |
$139.65
|
|
|
.ANTICARDIOLIPIN AB, IGA
|
Facility
|
IP
|
$53.00
|
|
|
Service Code
|
HCPCS 86147
|
| Hospital Charge Code |
4061471
|
|
Hospital Revenue Code
|
307
|
| Min. Negotiated Rate |
$37.10 |
| Max. Negotiated Rate |
$53.00 |
| Rate for Payer: Aetna Commercial |
$50.35
|
| Rate for Payer: Aetna Medicare |
$47.70
|
| Rate for Payer: BCBS MT CHIP |
$47.70
|
| Rate for Payer: BCBS MT Closed Plan Network |
$50.35
|
| Rate for Payer: BCBS MT HealthLink |
$47.70
|
| Rate for Payer: BCBS MT Medicare |
$47.70
|
| Rate for Payer: BCBS MT POS |
$50.35
|
| Rate for Payer: BCBS MT Traditional |
$53.00
|
| Rate for Payer: Cash Price |
$47.70
|
| Rate for Payer: Cigna Commercial |
$50.35
|
| Rate for Payer: Cigna Medicare |
$47.70
|
| Rate for Payer: Medicaid All Medicaid |
$48.76
|
| Rate for Payer: Medicare All Medicare |
$37.10
|
| Rate for Payer: Monida Allegiance |
$50.35
|
| Rate for Payer: Monida First Choice Health |
$51.41
|
| Rate for Payer: Monida Montana Health Co-op |
$50.35
|
| Rate for Payer: Monida PacificSource |
$50.35
|
|
|
.ANTICARDIOLIPIN AB, IGA
|
Facility
|
OP
|
$53.00
|
|
|
Service Code
|
HCPCS 86147
|
| Hospital Charge Code |
4061471
|
|
Hospital Revenue Code
|
307
|
| Min. Negotiated Rate |
$37.10 |
| Max. Negotiated Rate |
$53.00 |
| Rate for Payer: Aetna Commercial |
$50.35
|
| Rate for Payer: Aetna Medicare |
$47.70
|
| Rate for Payer: BCBS MT CHIP |
$47.70
|
| Rate for Payer: BCBS MT Closed Plan Network |
$50.35
|
| Rate for Payer: BCBS MT HealthLink |
$47.70
|
| Rate for Payer: BCBS MT Medicare |
$47.70
|
| Rate for Payer: BCBS MT POS |
$50.35
|
| Rate for Payer: BCBS MT Traditional |
$53.00
|
| Rate for Payer: Cash Price |
$47.70
|
| Rate for Payer: Cigna Commercial |
$50.35
|
| Rate for Payer: Cigna Medicare |
$47.70
|
| Rate for Payer: Medicaid All Medicaid |
$48.76
|
| Rate for Payer: Medicare All Medicare |
$37.10
|
| Rate for Payer: Monida Allegiance |
$50.35
|
| Rate for Payer: Monida First Choice Health |
$51.41
|
| Rate for Payer: Monida Montana Health Co-op |
$50.35
|
| Rate for Payer: Monida PacificSource |
$50.35
|
|
