|
KIDNEY STONE ANALYSIS (910180)
|
Facility
|
IP
|
$69.00
|
|
|
Service Code
|
CPT 82365
|
| Hospital Charge Code |
4082365
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$48.30 |
| Max. Negotiated Rate |
$69.00 |
| Rate for Payer: Aetna Commercial |
$65.55
|
| Rate for Payer: Aetna Medicare |
$62.10
|
| Rate for Payer: BCBS MT CHIP |
$62.10
|
| Rate for Payer: BCBS MT Closed Plan Network |
$65.55
|
| Rate for Payer: BCBS MT HealthLink |
$62.10
|
| Rate for Payer: BCBS MT Medicare |
$62.10
|
| Rate for Payer: BCBS MT POS |
$65.55
|
| Rate for Payer: BCBS MT Traditional |
$69.00
|
| Rate for Payer: Cash Price |
$62.10
|
| Rate for Payer: Cigna Commercial |
$65.55
|
| Rate for Payer: Cigna Medicare |
$62.10
|
| Rate for Payer: Medicaid All Medicaid |
$63.48
|
| Rate for Payer: Medicare All Medicare |
$48.30
|
| Rate for Payer: Monida Allegiance |
$65.55
|
| Rate for Payer: Monida First Choice Health |
$66.93
|
| Rate for Payer: Monida Montana Health Co-op |
$65.55
|
| Rate for Payer: Monida PacificSource |
$65.55
|
|
|
KING AIRWAY SIZE 3
|
Facility
|
IP
|
$167.00
|
|
| Hospital Charge Code |
80040150
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$116.90 |
| Max. Negotiated Rate |
$167.00 |
| Rate for Payer: Aetna Commercial |
$158.65
|
| Rate for Payer: Aetna Medicare |
$150.30
|
| Rate for Payer: BCBS MT CHIP |
$150.30
|
| Rate for Payer: BCBS MT Closed Plan Network |
$158.65
|
| Rate for Payer: BCBS MT HealthLink |
$150.30
|
| Rate for Payer: BCBS MT Medicare |
$150.30
|
| Rate for Payer: BCBS MT POS |
$158.65
|
| Rate for Payer: BCBS MT Traditional |
$167.00
|
| Rate for Payer: Cash Price |
$150.30
|
| Rate for Payer: Cigna Commercial |
$158.65
|
| Rate for Payer: Cigna Medicare |
$150.30
|
| Rate for Payer: Medicaid All Medicaid |
$153.64
|
| Rate for Payer: Medicare All Medicare |
$116.90
|
| Rate for Payer: Monida Allegiance |
$158.65
|
| Rate for Payer: Monida First Choice Health |
$161.99
|
| Rate for Payer: Monida Montana Health Co-op |
$158.65
|
| Rate for Payer: Monida PacificSource |
$158.65
|
|
|
KING AIRWAY SIZE 3
|
Facility
|
OP
|
$167.00
|
|
| Hospital Charge Code |
80040150
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$116.90 |
| Max. Negotiated Rate |
$167.00 |
| Rate for Payer: Aetna Commercial |
$158.65
|
| Rate for Payer: Aetna Medicare |
$150.30
|
| Rate for Payer: BCBS MT CHIP |
$150.30
|
| Rate for Payer: BCBS MT Closed Plan Network |
$158.65
|
| Rate for Payer: BCBS MT HealthLink |
$150.30
|
| Rate for Payer: BCBS MT Medicare |
$150.30
|
| Rate for Payer: BCBS MT POS |
$158.65
|
| Rate for Payer: BCBS MT Traditional |
$167.00
|
| Rate for Payer: Cash Price |
$150.30
|
| Rate for Payer: Cigna Commercial |
$158.65
|
| Rate for Payer: Cigna Medicare |
$150.30
|
| Rate for Payer: Medicaid All Medicaid |
$153.64
|
| Rate for Payer: Medicare All Medicare |
$116.90
|
| Rate for Payer: Monida Allegiance |
$158.65
|
| Rate for Payer: Monida First Choice Health |
$161.99
|
| Rate for Payer: Monida Montana Health Co-op |
$158.65
|
| Rate for Payer: Monida PacificSource |
$158.65
|
|
|
KIT COLLECTION
|
Facility
|
OP
|
$28.00
|
|
|
Service Code
|
CPT 99000
|
| Hospital Charge Code |
4099002
|
|
Hospital Revenue Code
|
300
|
| 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 MT CHIP |
$25.20
|
| Rate for Payer: BCBS MT Closed Plan Network |
$26.60
|
| Rate for Payer: BCBS MT HealthLink |
$25.20
|
| Rate for Payer: BCBS MT Medicare |
$25.20
|
| Rate for Payer: BCBS MT POS |
$26.60
|
| Rate for Payer: BCBS MT Traditional |
$28.00
|
| Rate for Payer: Cash Price |
$25.20
|
| Rate for Payer: Cigna Commercial |
$26.60
|
| Rate for Payer: Cigna Medicare |
$25.20
|
| Rate for Payer: Medicaid All Medicaid |
$25.76
|
| Rate for Payer: Medicare All Medicare |
$19.60
|
| Rate for Payer: Monida Allegiance |
$26.60
|
| Rate for Payer: Monida First Choice Health |
$27.16
|
| Rate for Payer: Monida Montana Health Co-op |
$26.60
|
| Rate for Payer: Monida PacificSource |
$26.60
|
|
|
KIT COLLECTION
|
Facility
|
IP
|
$28.00
|
|
|
Service Code
|
CPT 99000
|
| Hospital Charge Code |
4099002
|
|
Hospital Revenue Code
|
300
|
| 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 MT CHIP |
$25.20
|
| Rate for Payer: BCBS MT Closed Plan Network |
$26.60
|
| Rate for Payer: BCBS MT HealthLink |
$25.20
|
| Rate for Payer: BCBS MT Medicare |
$25.20
|
| Rate for Payer: BCBS MT POS |
$26.60
|
| Rate for Payer: BCBS MT Traditional |
$28.00
|
| Rate for Payer: Cash Price |
$25.20
|
| Rate for Payer: Cigna Commercial |
$26.60
|
| Rate for Payer: Cigna Medicare |
$25.20
|
| Rate for Payer: Medicaid All Medicaid |
$25.76
|
| Rate for Payer: Medicare All Medicare |
$19.60
|
| Rate for Payer: Monida Allegiance |
$26.60
|
| Rate for Payer: Monida First Choice Health |
$27.16
|
| Rate for Payer: Monida Montana Health Co-op |
$26.60
|
| Rate for Payer: Monida PacificSource |
$26.60
|
|
|
KNEE BRACE HINGED
|
Facility
|
OP
|
$68.00
|
|
|
Service Code
|
HCPCS L1833
|
| Hospital Charge Code |
8001833
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$47.60 |
| Max. Negotiated Rate |
$68.00 |
| Rate for Payer: Aetna Commercial |
$64.60
|
| Rate for Payer: Aetna Medicare |
$61.20
|
| Rate for Payer: BCBS MT CHIP |
$61.20
|
| Rate for Payer: BCBS MT Closed Plan Network |
$64.60
|
| Rate for Payer: BCBS MT HealthLink |
$61.20
|
| Rate for Payer: BCBS MT Medicare |
$61.20
|
| Rate for Payer: BCBS MT POS |
$64.60
|
| Rate for Payer: BCBS MT Traditional |
$68.00
|
| Rate for Payer: Cash Price |
$61.20
|
| Rate for Payer: Cigna Commercial |
$64.60
|
| Rate for Payer: Cigna Medicare |
$61.20
|
| Rate for Payer: Medicaid All Medicaid |
$62.56
|
| Rate for Payer: Medicare All Medicare |
$47.60
|
| Rate for Payer: Monida Allegiance |
$64.60
|
| Rate for Payer: Monida First Choice Health |
$65.96
|
| Rate for Payer: Monida Montana Health Co-op |
$64.60
|
| Rate for Payer: Monida PacificSource |
$64.60
|
|
|
KNEE BRACE HINGED
|
Facility
|
IP
|
$68.00
|
|
|
Service Code
|
HCPCS L1833
|
| Hospital Charge Code |
8001833
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$47.60 |
| Max. Negotiated Rate |
$68.00 |
| Rate for Payer: Aetna Commercial |
$64.60
|
| Rate for Payer: Aetna Medicare |
$61.20
|
| Rate for Payer: BCBS MT CHIP |
$61.20
|
| Rate for Payer: BCBS MT Closed Plan Network |
$64.60
|
| Rate for Payer: BCBS MT HealthLink |
$61.20
|
| Rate for Payer: BCBS MT Medicare |
$61.20
|
| Rate for Payer: BCBS MT POS |
$64.60
|
| Rate for Payer: BCBS MT Traditional |
$68.00
|
| Rate for Payer: Cash Price |
$61.20
|
| Rate for Payer: Cigna Commercial |
$64.60
|
| Rate for Payer: Cigna Medicare |
$61.20
|
| Rate for Payer: Medicaid All Medicaid |
$62.56
|
| Rate for Payer: Medicare All Medicare |
$47.60
|
| Rate for Payer: Monida Allegiance |
$64.60
|
| Rate for Payer: Monida First Choice Health |
$65.96
|
| Rate for Payer: Monida Montana Health Co-op |
$64.60
|
| Rate for Payer: Monida PacificSource |
$64.60
|
|
|
KNEE IMMOBILIZER
|
Facility
|
OP
|
$195.00
|
|
|
Service Code
|
HCPCS L1830
|
| Hospital Charge Code |
8001830
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$136.50 |
| Max. Negotiated Rate |
$195.00 |
| Rate for Payer: Aetna Commercial |
$185.25
|
| Rate for Payer: Aetna Medicare |
$175.50
|
| Rate for Payer: BCBS MT CHIP |
$175.50
|
| Rate for Payer: BCBS MT Closed Plan Network |
$185.25
|
| Rate for Payer: BCBS MT HealthLink |
$175.50
|
| Rate for Payer: BCBS MT Medicare |
$175.50
|
| Rate for Payer: BCBS MT POS |
$185.25
|
| Rate for Payer: BCBS MT Traditional |
$195.00
|
| Rate for Payer: Cash Price |
$175.50
|
| Rate for Payer: Cigna Commercial |
$185.25
|
| Rate for Payer: Cigna Medicare |
$175.50
|
| Rate for Payer: Medicaid All Medicaid |
$179.40
|
| Rate for Payer: Medicare All Medicare |
$136.50
|
| Rate for Payer: Monida Allegiance |
$185.25
|
| Rate for Payer: Monida First Choice Health |
$189.15
|
| Rate for Payer: Monida Montana Health Co-op |
$185.25
|
| Rate for Payer: Monida PacificSource |
$185.25
|
|
|
KNEE IMMOBILIZER
|
Facility
|
IP
|
$195.00
|
|
|
Service Code
|
HCPCS L1830
|
| Hospital Charge Code |
8001830
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$136.50 |
| Max. Negotiated Rate |
$195.00 |
| Rate for Payer: Aetna Commercial |
$185.25
|
| Rate for Payer: Aetna Medicare |
$175.50
|
| Rate for Payer: BCBS MT CHIP |
$175.50
|
| Rate for Payer: BCBS MT Closed Plan Network |
$185.25
|
| Rate for Payer: BCBS MT HealthLink |
$175.50
|
| Rate for Payer: BCBS MT Medicare |
$175.50
|
| Rate for Payer: BCBS MT POS |
$185.25
|
| Rate for Payer: BCBS MT Traditional |
$195.00
|
| Rate for Payer: Cash Price |
$175.50
|
| Rate for Payer: Cigna Commercial |
$185.25
|
| Rate for Payer: Cigna Medicare |
$175.50
|
| Rate for Payer: Medicaid All Medicaid |
$179.40
|
| Rate for Payer: Medicare All Medicare |
$136.50
|
| Rate for Payer: Monida Allegiance |
$185.25
|
| Rate for Payer: Monida First Choice Health |
$189.15
|
| Rate for Payer: Monida Montana Health Co-op |
$185.25
|
| Rate for Payer: Monida PacificSource |
$185.25
|
|
|
KNEE SLEEVE LG SHORT
|
Facility
|
OP
|
$32.00
|
|
| Hospital Charge Code |
2893370
|
|
Hospital Revenue Code
|
290
|
| 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 MT CHIP |
$28.80
|
| Rate for Payer: BCBS MT Closed Plan Network |
$30.40
|
| Rate for Payer: BCBS MT HealthLink |
$28.80
|
| Rate for Payer: BCBS MT Medicare |
$28.80
|
| Rate for Payer: BCBS MT POS |
$30.40
|
| Rate for Payer: BCBS MT Traditional |
$32.00
|
| Rate for Payer: Cash Price |
$28.80
|
| Rate for Payer: Cigna Commercial |
$30.40
|
| Rate for Payer: Cigna Medicare |
$28.80
|
| Rate for Payer: Medicaid All Medicaid |
$29.44
|
| Rate for Payer: Medicare All Medicare |
$22.40
|
| Rate for Payer: Monida Allegiance |
$30.40
|
| Rate for Payer: Monida First Choice Health |
$31.04
|
| Rate for Payer: Monida Montana Health Co-op |
$30.40
|
| Rate for Payer: Monida PacificSource |
$30.40
|
|
|
KNEE SLEEVE LG SHORT
|
Facility
|
IP
|
$32.00
|
|
| Hospital Charge Code |
2893370
|
|
Hospital Revenue Code
|
290
|
| 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 MT CHIP |
$28.80
|
| Rate for Payer: BCBS MT Closed Plan Network |
$30.40
|
| Rate for Payer: BCBS MT HealthLink |
$28.80
|
| Rate for Payer: BCBS MT Medicare |
$28.80
|
| Rate for Payer: BCBS MT POS |
$30.40
|
| Rate for Payer: BCBS MT Traditional |
$32.00
|
| Rate for Payer: Cash Price |
$28.80
|
| Rate for Payer: Cigna Commercial |
$30.40
|
| Rate for Payer: Cigna Medicare |
$28.80
|
| Rate for Payer: Medicaid All Medicaid |
$29.44
|
| Rate for Payer: Medicare All Medicare |
$22.40
|
| Rate for Payer: Monida Allegiance |
$30.40
|
| Rate for Payer: Monida First Choice Health |
$31.04
|
| Rate for Payer: Monida Montana Health Co-op |
$30.40
|
| Rate for Payer: Monida PacificSource |
$30.40
|
|
|
KNEE SLEEVE MED
|
Facility
|
IP
|
$32.00
|
|
| Hospital Charge Code |
2893369
|
|
Hospital Revenue Code
|
290
|
| 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 MT CHIP |
$28.80
|
| Rate for Payer: BCBS MT Closed Plan Network |
$30.40
|
| Rate for Payer: BCBS MT HealthLink |
$28.80
|
| Rate for Payer: BCBS MT Medicare |
$28.80
|
| Rate for Payer: BCBS MT POS |
$30.40
|
| Rate for Payer: BCBS MT Traditional |
$32.00
|
| Rate for Payer: Cash Price |
$28.80
|
| Rate for Payer: Cigna Commercial |
$30.40
|
| Rate for Payer: Cigna Medicare |
$28.80
|
| Rate for Payer: Medicaid All Medicaid |
$29.44
|
| Rate for Payer: Medicare All Medicare |
$22.40
|
| Rate for Payer: Monida Allegiance |
$30.40
|
| Rate for Payer: Monida First Choice Health |
$31.04
|
| Rate for Payer: Monida Montana Health Co-op |
$30.40
|
| Rate for Payer: Monida PacificSource |
$30.40
|
|
|
KNEE SLEEVE MED
|
Facility
|
OP
|
$32.00
|
|
| Hospital Charge Code |
2893369
|
|
Hospital Revenue Code
|
290
|
| 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 MT CHIP |
$28.80
|
| Rate for Payer: BCBS MT Closed Plan Network |
$30.40
|
| Rate for Payer: BCBS MT HealthLink |
$28.80
|
| Rate for Payer: BCBS MT Medicare |
$28.80
|
| Rate for Payer: BCBS MT POS |
$30.40
|
| Rate for Payer: BCBS MT Traditional |
$32.00
|
| Rate for Payer: Cash Price |
$28.80
|
| Rate for Payer: Cigna Commercial |
$30.40
|
| Rate for Payer: Cigna Medicare |
$28.80
|
| Rate for Payer: Medicaid All Medicaid |
$29.44
|
| Rate for Payer: Medicare All Medicare |
$22.40
|
| Rate for Payer: Monida Allegiance |
$30.40
|
| Rate for Payer: Monida First Choice Health |
$31.04
|
| Rate for Payer: Monida Montana Health Co-op |
$30.40
|
| Rate for Payer: Monida PacificSource |
$30.40
|
|
|
KNEE SLEEVE SM
|
Facility
|
IP
|
$37.00
|
|
| Hospital Charge Code |
2820014
|
|
Hospital Revenue Code
|
270
|
| 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 MT CHIP |
$33.30
|
| Rate for Payer: BCBS MT Closed Plan Network |
$35.15
|
| Rate for Payer: BCBS MT HealthLink |
$33.30
|
| Rate for Payer: BCBS MT Medicare |
$33.30
|
| Rate for Payer: BCBS MT POS |
$35.15
|
| Rate for Payer: BCBS MT Traditional |
$37.00
|
| Rate for Payer: Cash Price |
$33.30
|
| Rate for Payer: Cigna Commercial |
$35.15
|
| Rate for Payer: Cigna Medicare |
$33.30
|
| Rate for Payer: Medicaid All Medicaid |
$34.04
|
| Rate for Payer: Medicare All Medicare |
$25.90
|
| Rate for Payer: Monida Allegiance |
$35.15
|
| Rate for Payer: Monida First Choice Health |
$35.89
|
| Rate for Payer: Monida Montana Health Co-op |
$35.15
|
| Rate for Payer: Monida PacificSource |
$35.15
|
|
|
KNEE SLEEVE SM
|
Facility
|
OP
|
$37.00
|
|
| Hospital Charge Code |
2820014
|
|
Hospital Revenue Code
|
270
|
| 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 MT CHIP |
$33.30
|
| Rate for Payer: BCBS MT Closed Plan Network |
$35.15
|
| Rate for Payer: BCBS MT HealthLink |
$33.30
|
| Rate for Payer: BCBS MT Medicare |
$33.30
|
| Rate for Payer: BCBS MT POS |
$35.15
|
| Rate for Payer: BCBS MT Traditional |
$37.00
|
| Rate for Payer: Cash Price |
$33.30
|
| Rate for Payer: Cigna Commercial |
$35.15
|
| Rate for Payer: Cigna Medicare |
$33.30
|
| Rate for Payer: Medicaid All Medicaid |
$34.04
|
| Rate for Payer: Medicare All Medicare |
$25.90
|
| Rate for Payer: Monida Allegiance |
$35.15
|
| Rate for Payer: Monida First Choice Health |
$35.89
|
| Rate for Payer: Monida Montana Health Co-op |
$35.15
|
| Rate for Payer: Monida PacificSource |
$35.15
|
|
|
KNEE SLEEVE XLG
|
Facility
|
OP
|
$28.00
|
|
| Hospital Charge Code |
2893371
|
|
Hospital Revenue Code
|
290
|
| 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 MT CHIP |
$25.20
|
| Rate for Payer: BCBS MT Closed Plan Network |
$26.60
|
| Rate for Payer: BCBS MT HealthLink |
$25.20
|
| Rate for Payer: BCBS MT Medicare |
$25.20
|
| Rate for Payer: BCBS MT POS |
$26.60
|
| Rate for Payer: BCBS MT Traditional |
$28.00
|
| Rate for Payer: Cash Price |
$25.20
|
| Rate for Payer: Cigna Commercial |
$26.60
|
| Rate for Payer: Cigna Medicare |
$25.20
|
| Rate for Payer: Medicaid All Medicaid |
$25.76
|
| Rate for Payer: Medicare All Medicare |
$19.60
|
| Rate for Payer: Monida Allegiance |
$26.60
|
| Rate for Payer: Monida First Choice Health |
$27.16
|
| Rate for Payer: Monida Montana Health Co-op |
$26.60
|
| Rate for Payer: Monida PacificSource |
$26.60
|
|
|
KNEE SLEEVE XLG
|
Facility
|
IP
|
$28.00
|
|
| Hospital Charge Code |
2893371
|
|
Hospital Revenue Code
|
290
|
| 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 MT CHIP |
$25.20
|
| Rate for Payer: BCBS MT Closed Plan Network |
$26.60
|
| Rate for Payer: BCBS MT HealthLink |
$25.20
|
| Rate for Payer: BCBS MT Medicare |
$25.20
|
| Rate for Payer: BCBS MT POS |
$26.60
|
| Rate for Payer: BCBS MT Traditional |
$28.00
|
| Rate for Payer: Cash Price |
$25.20
|
| Rate for Payer: Cigna Commercial |
$26.60
|
| Rate for Payer: Cigna Medicare |
$25.20
|
| Rate for Payer: Medicaid All Medicaid |
$25.76
|
| Rate for Payer: Medicare All Medicare |
$19.60
|
| Rate for Payer: Monida Allegiance |
$26.60
|
| Rate for Payer: Monida First Choice Health |
$27.16
|
| Rate for Payer: Monida Montana Health Co-op |
$26.60
|
| Rate for Payer: Monida PacificSource |
$26.60
|
|
|
KNEE SPLINT 18 - 20'' UNIVERSA
|
Facility
|
OP
|
$64.00
|
|
| Hospital Charge Code |
2820013
|
|
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
|
|
|
KNEE SPLINT 18 - 20'' UNIVERSA
|
Facility
|
IP
|
$64.00
|
|
| Hospital Charge Code |
2820013
|
|
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
|
|
|
KNEE SPLINT 20' XL
|
Facility
|
IP
|
$54.00
|
|
| Hospital Charge Code |
2893362
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$37.80 |
| Max. Negotiated Rate |
$54.00 |
| Rate for Payer: Aetna Commercial |
$51.30
|
| Rate for Payer: Aetna Medicare |
$48.60
|
| Rate for Payer: BCBS MT CHIP |
$48.60
|
| Rate for Payer: BCBS MT Closed Plan Network |
$51.30
|
| Rate for Payer: BCBS MT HealthLink |
$48.60
|
| Rate for Payer: BCBS MT Medicare |
$48.60
|
| Rate for Payer: BCBS MT POS |
$51.30
|
| Rate for Payer: BCBS MT Traditional |
$54.00
|
| Rate for Payer: Cash Price |
$48.60
|
| Rate for Payer: Cigna Commercial |
$51.30
|
| Rate for Payer: Cigna Medicare |
$48.60
|
| Rate for Payer: Medicaid All Medicaid |
$49.68
|
| Rate for Payer: Medicare All Medicare |
$37.80
|
| Rate for Payer: Monida Allegiance |
$51.30
|
| Rate for Payer: Monida First Choice Health |
$52.38
|
| Rate for Payer: Monida Montana Health Co-op |
$51.30
|
| Rate for Payer: Monida PacificSource |
$51.30
|
|
|
KNEE SPLINT 20' XL
|
Facility
|
OP
|
$54.00
|
|
| Hospital Charge Code |
2893362
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$37.80 |
| Max. Negotiated Rate |
$54.00 |
| Rate for Payer: Aetna Commercial |
$51.30
|
| Rate for Payer: Aetna Medicare |
$48.60
|
| Rate for Payer: BCBS MT CHIP |
$48.60
|
| Rate for Payer: BCBS MT Closed Plan Network |
$51.30
|
| Rate for Payer: BCBS MT HealthLink |
$48.60
|
| Rate for Payer: BCBS MT Medicare |
$48.60
|
| Rate for Payer: BCBS MT POS |
$51.30
|
| Rate for Payer: BCBS MT Traditional |
$54.00
|
| Rate for Payer: Cash Price |
$48.60
|
| Rate for Payer: Cigna Commercial |
$51.30
|
| Rate for Payer: Cigna Medicare |
$48.60
|
| Rate for Payer: Medicaid All Medicaid |
$49.68
|
| Rate for Payer: Medicare All Medicare |
$37.80
|
| Rate for Payer: Monida Allegiance |
$51.30
|
| Rate for Payer: Monida First Choice Health |
$52.38
|
| Rate for Payer: Monida Montana Health Co-op |
$51.30
|
| Rate for Payer: Monida PacificSource |
$51.30
|
|
|
KNEE SPLINT 20'' XXL
|
Facility
|
IP
|
$54.00
|
|
| Hospital Charge Code |
2893363
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$37.80 |
| Max. Negotiated Rate |
$54.00 |
| Rate for Payer: Aetna Commercial |
$51.30
|
| Rate for Payer: Aetna Medicare |
$48.60
|
| Rate for Payer: BCBS MT CHIP |
$48.60
|
| Rate for Payer: BCBS MT Closed Plan Network |
$51.30
|
| Rate for Payer: BCBS MT HealthLink |
$48.60
|
| Rate for Payer: BCBS MT Medicare |
$48.60
|
| Rate for Payer: BCBS MT POS |
$51.30
|
| Rate for Payer: BCBS MT Traditional |
$54.00
|
| Rate for Payer: Cash Price |
$48.60
|
| Rate for Payer: Cigna Commercial |
$51.30
|
| Rate for Payer: Cigna Medicare |
$48.60
|
| Rate for Payer: Medicaid All Medicaid |
$49.68
|
| Rate for Payer: Medicare All Medicare |
$37.80
|
| Rate for Payer: Monida Allegiance |
$51.30
|
| Rate for Payer: Monida First Choice Health |
$52.38
|
| Rate for Payer: Monida Montana Health Co-op |
$51.30
|
| Rate for Payer: Monida PacificSource |
$51.30
|
|
|
KNEE SPLINT 20'' XXL
|
Facility
|
OP
|
$54.00
|
|
| Hospital Charge Code |
2893363
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$37.80 |
| Max. Negotiated Rate |
$54.00 |
| Rate for Payer: Aetna Commercial |
$51.30
|
| Rate for Payer: Aetna Medicare |
$48.60
|
| Rate for Payer: BCBS MT CHIP |
$48.60
|
| Rate for Payer: BCBS MT Closed Plan Network |
$51.30
|
| Rate for Payer: BCBS MT HealthLink |
$48.60
|
| Rate for Payer: BCBS MT Medicare |
$48.60
|
| Rate for Payer: BCBS MT POS |
$51.30
|
| Rate for Payer: BCBS MT Traditional |
$54.00
|
| Rate for Payer: Cash Price |
$48.60
|
| Rate for Payer: Cigna Commercial |
$51.30
|
| Rate for Payer: Cigna Medicare |
$48.60
|
| Rate for Payer: Medicaid All Medicaid |
$49.68
|
| Rate for Payer: Medicare All Medicare |
$37.80
|
| Rate for Payer: Monida Allegiance |
$51.30
|
| Rate for Payer: Monida First Choice Health |
$52.38
|
| Rate for Payer: Monida Montana Health Co-op |
$51.30
|
| Rate for Payer: Monida PacificSource |
$51.30
|
|
|
KNEE SPLINT 22' LG
|
Facility
|
OP
|
$63.00
|
|
| Hospital Charge Code |
2893365
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$44.10 |
| Max. Negotiated Rate |
$63.00 |
| Rate for Payer: Aetna Commercial |
$59.85
|
| Rate for Payer: Aetna Medicare |
$56.70
|
| Rate for Payer: BCBS MT CHIP |
$56.70
|
| Rate for Payer: BCBS MT Closed Plan Network |
$59.85
|
| Rate for Payer: BCBS MT HealthLink |
$56.70
|
| Rate for Payer: BCBS MT Medicare |
$56.70
|
| Rate for Payer: BCBS MT POS |
$59.85
|
| Rate for Payer: BCBS MT Traditional |
$63.00
|
| Rate for Payer: Cash Price |
$56.70
|
| Rate for Payer: Cigna Commercial |
$59.85
|
| Rate for Payer: Cigna Medicare |
$56.70
|
| Rate for Payer: Medicaid All Medicaid |
$57.96
|
| Rate for Payer: Medicare All Medicare |
$44.10
|
| Rate for Payer: Monida Allegiance |
$59.85
|
| Rate for Payer: Monida First Choice Health |
$61.11
|
| Rate for Payer: Monida Montana Health Co-op |
$59.85
|
| Rate for Payer: Monida PacificSource |
$59.85
|
|
|
KNEE SPLINT 22' LG
|
Facility
|
IP
|
$63.00
|
|
| Hospital Charge Code |
2893365
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$44.10 |
| Max. Negotiated Rate |
$63.00 |
| Rate for Payer: Aetna Commercial |
$59.85
|
| Rate for Payer: Aetna Medicare |
$56.70
|
| Rate for Payer: BCBS MT CHIP |
$56.70
|
| Rate for Payer: BCBS MT Closed Plan Network |
$59.85
|
| Rate for Payer: BCBS MT HealthLink |
$56.70
|
| Rate for Payer: BCBS MT Medicare |
$56.70
|
| Rate for Payer: BCBS MT POS |
$59.85
|
| Rate for Payer: BCBS MT Traditional |
$63.00
|
| Rate for Payer: Cash Price |
$56.70
|
| Rate for Payer: Cigna Commercial |
$59.85
|
| Rate for Payer: Cigna Medicare |
$56.70
|
| Rate for Payer: Medicaid All Medicaid |
$57.96
|
| Rate for Payer: Medicare All Medicare |
$44.10
|
| Rate for Payer: Monida Allegiance |
$59.85
|
| Rate for Payer: Monida First Choice Health |
$61.11
|
| Rate for Payer: Monida Montana Health Co-op |
$59.85
|
| Rate for Payer: Monida PacificSource |
$59.85
|
|
