|
KNEE SPLINT 22' MED
|
Facility
|
OP
|
$63.00
|
|
| Hospital Charge Code |
2893364
|
|
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' MED
|
Facility
|
IP
|
$63.00
|
|
| Hospital Charge Code |
2893364
|
|
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 SPORT SLEEVE
|
Facility
|
OP
|
$289.00
|
|
|
Service Code
|
HCPCS L1820
|
| Hospital Charge Code |
8001800
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$202.30 |
| Max. Negotiated Rate |
$289.00 |
| Rate for Payer: Aetna Commercial |
$274.55
|
| Rate for Payer: Aetna Medicare |
$260.10
|
| Rate for Payer: BCBS MT CHIP |
$260.10
|
| Rate for Payer: BCBS MT Closed Plan Network |
$274.55
|
| Rate for Payer: BCBS MT HealthLink |
$260.10
|
| Rate for Payer: BCBS MT Medicare |
$260.10
|
| Rate for Payer: BCBS MT POS |
$274.55
|
| Rate for Payer: BCBS MT Traditional |
$289.00
|
| Rate for Payer: Cash Price |
$260.10
|
| Rate for Payer: Cigna Commercial |
$274.55
|
| Rate for Payer: Cigna Medicare |
$260.10
|
| Rate for Payer: Medicaid All Medicaid |
$265.88
|
| Rate for Payer: Medicare All Medicare |
$202.30
|
| Rate for Payer: Monida Allegiance |
$274.55
|
| Rate for Payer: Monida First Choice Health |
$280.33
|
| Rate for Payer: Monida Montana Health Co-op |
$274.55
|
| Rate for Payer: Monida PacificSource |
$274.55
|
|
|
KNEE SPORT SLEEVE
|
Facility
|
IP
|
$289.00
|
|
|
Service Code
|
HCPCS L1820
|
| Hospital Charge Code |
8001800
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$202.30 |
| Max. Negotiated Rate |
$289.00 |
| Rate for Payer: Aetna Commercial |
$274.55
|
| Rate for Payer: Aetna Medicare |
$260.10
|
| Rate for Payer: BCBS MT CHIP |
$260.10
|
| Rate for Payer: BCBS MT Closed Plan Network |
$274.55
|
| Rate for Payer: BCBS MT HealthLink |
$260.10
|
| Rate for Payer: BCBS MT Medicare |
$260.10
|
| Rate for Payer: BCBS MT POS |
$274.55
|
| Rate for Payer: BCBS MT Traditional |
$289.00
|
| Rate for Payer: Cash Price |
$260.10
|
| Rate for Payer: Cigna Commercial |
$274.55
|
| Rate for Payer: Cigna Medicare |
$260.10
|
| Rate for Payer: Medicaid All Medicaid |
$265.88
|
| Rate for Payer: Medicare All Medicare |
$202.30
|
| Rate for Payer: Monida Allegiance |
$274.55
|
| Rate for Payer: Monida First Choice Health |
$280.33
|
| Rate for Payer: Monida Montana Health Co-op |
$274.55
|
| Rate for Payer: Monida PacificSource |
$274.55
|
|
|
KNEE STABILIZER LG LONG
|
Facility
|
OP
|
$81.00
|
|
| Hospital Charge Code |
2893366
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$56.70 |
| Max. Negotiated Rate |
$81.00 |
| Rate for Payer: Aetna Commercial |
$76.95
|
| Rate for Payer: Aetna Medicare |
$72.90
|
| Rate for Payer: BCBS MT CHIP |
$72.90
|
| Rate for Payer: BCBS MT Closed Plan Network |
$76.95
|
| Rate for Payer: BCBS MT HealthLink |
$72.90
|
| Rate for Payer: BCBS MT Medicare |
$72.90
|
| Rate for Payer: BCBS MT POS |
$76.95
|
| Rate for Payer: BCBS MT Traditional |
$81.00
|
| Rate for Payer: Cash Price |
$72.90
|
| Rate for Payer: Cigna Commercial |
$76.95
|
| Rate for Payer: Cigna Medicare |
$72.90
|
| Rate for Payer: Medicaid All Medicaid |
$74.52
|
| Rate for Payer: Medicare All Medicare |
$56.70
|
| Rate for Payer: Monida Allegiance |
$76.95
|
| Rate for Payer: Monida First Choice Health |
$78.57
|
| Rate for Payer: Monida Montana Health Co-op |
$76.95
|
| Rate for Payer: Monida PacificSource |
$76.95
|
|
|
KNEE STABILIZER LG LONG
|
Facility
|
IP
|
$81.00
|
|
| Hospital Charge Code |
2893366
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$56.70 |
| Max. Negotiated Rate |
$81.00 |
| Rate for Payer: Aetna Commercial |
$76.95
|
| Rate for Payer: Aetna Medicare |
$72.90
|
| Rate for Payer: BCBS MT CHIP |
$72.90
|
| Rate for Payer: BCBS MT Closed Plan Network |
$76.95
|
| Rate for Payer: BCBS MT HealthLink |
$72.90
|
| Rate for Payer: BCBS MT Medicare |
$72.90
|
| Rate for Payer: BCBS MT POS |
$76.95
|
| Rate for Payer: BCBS MT Traditional |
$81.00
|
| Rate for Payer: Cash Price |
$72.90
|
| Rate for Payer: Cigna Commercial |
$76.95
|
| Rate for Payer: Cigna Medicare |
$72.90
|
| Rate for Payer: Medicaid All Medicaid |
$74.52
|
| Rate for Payer: Medicare All Medicare |
$56.70
|
| Rate for Payer: Monida Allegiance |
$76.95
|
| Rate for Payer: Monida First Choice Health |
$78.57
|
| Rate for Payer: Monida Montana Health Co-op |
$76.95
|
| Rate for Payer: Monida PacificSource |
$76.95
|
|
|
KNEE STABILIZER MED LONG
|
Facility
|
IP
|
$95.00
|
|
| Hospital Charge Code |
2820012
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$66.50 |
| Max. Negotiated Rate |
$95.00 |
| Rate for Payer: Aetna Commercial |
$90.25
|
| Rate for Payer: Aetna Medicare |
$85.50
|
| Rate for Payer: BCBS MT CHIP |
$85.50
|
| Rate for Payer: BCBS MT Closed Plan Network |
$90.25
|
| Rate for Payer: BCBS MT HealthLink |
$85.50
|
| Rate for Payer: BCBS MT Medicare |
$85.50
|
| Rate for Payer: BCBS MT POS |
$90.25
|
| Rate for Payer: BCBS MT Traditional |
$95.00
|
| Rate for Payer: Cash Price |
$85.50
|
| Rate for Payer: Cigna Commercial |
$90.25
|
| Rate for Payer: Cigna Medicare |
$85.50
|
| Rate for Payer: Medicaid All Medicaid |
$87.40
|
| Rate for Payer: Medicare All Medicare |
$66.50
|
| Rate for Payer: Monida Allegiance |
$90.25
|
| Rate for Payer: Monida First Choice Health |
$92.15
|
| Rate for Payer: Monida Montana Health Co-op |
$90.25
|
| Rate for Payer: Monida PacificSource |
$90.25
|
|
|
KNEE STABILIZER MED LONG
|
Facility
|
OP
|
$95.00
|
|
| Hospital Charge Code |
2820012
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$66.50 |
| Max. Negotiated Rate |
$95.00 |
| Rate for Payer: Aetna Commercial |
$90.25
|
| Rate for Payer: Aetna Medicare |
$85.50
|
| Rate for Payer: BCBS MT CHIP |
$85.50
|
| Rate for Payer: BCBS MT Closed Plan Network |
$90.25
|
| Rate for Payer: BCBS MT HealthLink |
$85.50
|
| Rate for Payer: BCBS MT Medicare |
$85.50
|
| Rate for Payer: BCBS MT POS |
$90.25
|
| Rate for Payer: BCBS MT Traditional |
$95.00
|
| Rate for Payer: Cash Price |
$85.50
|
| Rate for Payer: Cigna Commercial |
$90.25
|
| Rate for Payer: Cigna Medicare |
$85.50
|
| Rate for Payer: Medicaid All Medicaid |
$87.40
|
| Rate for Payer: Medicare All Medicare |
$66.50
|
| Rate for Payer: Monida Allegiance |
$90.25
|
| Rate for Payer: Monida First Choice Health |
$92.15
|
| Rate for Payer: Monida Montana Health Co-op |
$90.25
|
| Rate for Payer: Monida PacificSource |
$90.25
|
|
|
KNEE STABILIZER SM
|
Facility
|
IP
|
$81.00
|
|
| Hospital Charge Code |
2893368
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$56.70 |
| Max. Negotiated Rate |
$81.00 |
| Rate for Payer: Aetna Commercial |
$76.95
|
| Rate for Payer: Aetna Medicare |
$72.90
|
| Rate for Payer: BCBS MT CHIP |
$72.90
|
| Rate for Payer: BCBS MT Closed Plan Network |
$76.95
|
| Rate for Payer: BCBS MT HealthLink |
$72.90
|
| Rate for Payer: BCBS MT Medicare |
$72.90
|
| Rate for Payer: BCBS MT POS |
$76.95
|
| Rate for Payer: BCBS MT Traditional |
$81.00
|
| Rate for Payer: Cash Price |
$72.90
|
| Rate for Payer: Cigna Commercial |
$76.95
|
| Rate for Payer: Cigna Medicare |
$72.90
|
| Rate for Payer: Medicaid All Medicaid |
$74.52
|
| Rate for Payer: Medicare All Medicare |
$56.70
|
| Rate for Payer: Monida Allegiance |
$76.95
|
| Rate for Payer: Monida First Choice Health |
$78.57
|
| Rate for Payer: Monida Montana Health Co-op |
$76.95
|
| Rate for Payer: Monida PacificSource |
$76.95
|
|
|
KNEE STABILIZER SM
|
Facility
|
OP
|
$81.00
|
|
| Hospital Charge Code |
2893368
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$56.70 |
| Max. Negotiated Rate |
$81.00 |
| Rate for Payer: Aetna Commercial |
$76.95
|
| Rate for Payer: Aetna Medicare |
$72.90
|
| Rate for Payer: BCBS MT CHIP |
$72.90
|
| Rate for Payer: BCBS MT Closed Plan Network |
$76.95
|
| Rate for Payer: BCBS MT HealthLink |
$72.90
|
| Rate for Payer: BCBS MT Medicare |
$72.90
|
| Rate for Payer: BCBS MT POS |
$76.95
|
| Rate for Payer: BCBS MT Traditional |
$81.00
|
| Rate for Payer: Cash Price |
$72.90
|
| Rate for Payer: Cigna Commercial |
$76.95
|
| Rate for Payer: Cigna Medicare |
$72.90
|
| Rate for Payer: Medicaid All Medicaid |
$74.52
|
| Rate for Payer: Medicare All Medicare |
$56.70
|
| Rate for Payer: Monida Allegiance |
$76.95
|
| Rate for Payer: Monida First Choice Health |
$78.57
|
| Rate for Payer: Monida Montana Health Co-op |
$76.95
|
| Rate for Payer: Monida PacificSource |
$76.95
|
|
|
KNEE STABILIZER XL LONG
|
Facility
|
IP
|
$81.00
|
|
| Hospital Charge Code |
2893367
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$56.70 |
| Max. Negotiated Rate |
$81.00 |
| Rate for Payer: Aetna Commercial |
$76.95
|
| Rate for Payer: Aetna Medicare |
$72.90
|
| Rate for Payer: BCBS MT CHIP |
$72.90
|
| Rate for Payer: BCBS MT Closed Plan Network |
$76.95
|
| Rate for Payer: BCBS MT HealthLink |
$72.90
|
| Rate for Payer: BCBS MT Medicare |
$72.90
|
| Rate for Payer: BCBS MT POS |
$76.95
|
| Rate for Payer: BCBS MT Traditional |
$81.00
|
| Rate for Payer: Cash Price |
$72.90
|
| Rate for Payer: Cigna Commercial |
$76.95
|
| Rate for Payer: Cigna Medicare |
$72.90
|
| Rate for Payer: Medicaid All Medicaid |
$74.52
|
| Rate for Payer: Medicare All Medicare |
$56.70
|
| Rate for Payer: Monida Allegiance |
$76.95
|
| Rate for Payer: Monida First Choice Health |
$78.57
|
| Rate for Payer: Monida Montana Health Co-op |
$76.95
|
| Rate for Payer: Monida PacificSource |
$76.95
|
|
|
KNEE STABILIZER XL LONG
|
Facility
|
OP
|
$81.00
|
|
| Hospital Charge Code |
2893367
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$56.70 |
| Max. Negotiated Rate |
$81.00 |
| Rate for Payer: Aetna Commercial |
$76.95
|
| Rate for Payer: Aetna Medicare |
$72.90
|
| Rate for Payer: BCBS MT CHIP |
$72.90
|
| Rate for Payer: BCBS MT Closed Plan Network |
$76.95
|
| Rate for Payer: BCBS MT HealthLink |
$72.90
|
| Rate for Payer: BCBS MT Medicare |
$72.90
|
| Rate for Payer: BCBS MT POS |
$76.95
|
| Rate for Payer: BCBS MT Traditional |
$81.00
|
| Rate for Payer: Cash Price |
$72.90
|
| Rate for Payer: Cigna Commercial |
$76.95
|
| Rate for Payer: Cigna Medicare |
$72.90
|
| Rate for Payer: Medicaid All Medicaid |
$74.52
|
| Rate for Payer: Medicare All Medicare |
$56.70
|
| Rate for Payer: Monida Allegiance |
$76.95
|
| Rate for Payer: Monida First Choice Health |
$78.57
|
| Rate for Payer: Monida Montana Health Co-op |
$76.95
|
| Rate for Payer: Monida PacificSource |
$76.95
|
|
|
KNEE SUPPORT W/PATELLA
|
Facility
|
OP
|
$289.00
|
|
|
Service Code
|
HCPCS L1820
|
| Hospital Charge Code |
8001820
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$202.30 |
| Max. Negotiated Rate |
$289.00 |
| Rate for Payer: Aetna Commercial |
$274.55
|
| Rate for Payer: Aetna Medicare |
$260.10
|
| Rate for Payer: BCBS MT CHIP |
$260.10
|
| Rate for Payer: BCBS MT Closed Plan Network |
$274.55
|
| Rate for Payer: BCBS MT HealthLink |
$260.10
|
| Rate for Payer: BCBS MT Medicare |
$260.10
|
| Rate for Payer: BCBS MT POS |
$274.55
|
| Rate for Payer: BCBS MT Traditional |
$289.00
|
| Rate for Payer: Cash Price |
$260.10
|
| Rate for Payer: Cigna Commercial |
$274.55
|
| Rate for Payer: Cigna Medicare |
$260.10
|
| Rate for Payer: Medicaid All Medicaid |
$265.88
|
| Rate for Payer: Medicare All Medicare |
$202.30
|
| Rate for Payer: Monida Allegiance |
$274.55
|
| Rate for Payer: Monida First Choice Health |
$280.33
|
| Rate for Payer: Monida Montana Health Co-op |
$274.55
|
| Rate for Payer: Monida PacificSource |
$274.55
|
|
|
KNEE SUPPORT W/PATELLA
|
Facility
|
IP
|
$289.00
|
|
|
Service Code
|
HCPCS L1820
|
| Hospital Charge Code |
8001820
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$202.30 |
| Max. Negotiated Rate |
$289.00 |
| Rate for Payer: Aetna Commercial |
$274.55
|
| Rate for Payer: Aetna Medicare |
$260.10
|
| Rate for Payer: BCBS MT CHIP |
$260.10
|
| Rate for Payer: BCBS MT Closed Plan Network |
$274.55
|
| Rate for Payer: BCBS MT HealthLink |
$260.10
|
| Rate for Payer: BCBS MT Medicare |
$260.10
|
| Rate for Payer: BCBS MT POS |
$274.55
|
| Rate for Payer: BCBS MT Traditional |
$289.00
|
| Rate for Payer: Cash Price |
$260.10
|
| Rate for Payer: Cigna Commercial |
$274.55
|
| Rate for Payer: Cigna Medicare |
$260.10
|
| Rate for Payer: Medicaid All Medicaid |
$265.88
|
| Rate for Payer: Medicare All Medicare |
$202.30
|
| Rate for Payer: Monida Allegiance |
$274.55
|
| Rate for Payer: Monida First Choice Health |
$280.33
|
| Rate for Payer: Monida Montana Health Co-op |
$274.55
|
| Rate for Payer: Monida PacificSource |
$274.55
|
|
|
KNEE WRAP HINGED LG
|
Facility
|
OP
|
$196.00
|
|
| Hospital Charge Code |
2893374
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$137.20 |
| Max. Negotiated Rate |
$196.00 |
| Rate for Payer: Aetna Commercial |
$186.20
|
| Rate for Payer: Aetna Medicare |
$176.40
|
| Rate for Payer: BCBS MT CHIP |
$176.40
|
| Rate for Payer: BCBS MT Closed Plan Network |
$186.20
|
| Rate for Payer: BCBS MT HealthLink |
$176.40
|
| Rate for Payer: BCBS MT Medicare |
$176.40
|
| Rate for Payer: BCBS MT POS |
$186.20
|
| Rate for Payer: BCBS MT Traditional |
$196.00
|
| Rate for Payer: Cash Price |
$176.40
|
| Rate for Payer: Cigna Commercial |
$186.20
|
| Rate for Payer: Cigna Medicare |
$176.40
|
| Rate for Payer: Medicaid All Medicaid |
$180.32
|
| Rate for Payer: Medicare All Medicare |
$137.20
|
| Rate for Payer: Monida Allegiance |
$186.20
|
| Rate for Payer: Monida First Choice Health |
$190.12
|
| Rate for Payer: Monida Montana Health Co-op |
$186.20
|
| Rate for Payer: Monida PacificSource |
$186.20
|
|
|
KNEE WRAP HINGED LG
|
Facility
|
IP
|
$196.00
|
|
| Hospital Charge Code |
2893374
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$137.20 |
| Max. Negotiated Rate |
$196.00 |
| Rate for Payer: Aetna Commercial |
$186.20
|
| Rate for Payer: Aetna Medicare |
$176.40
|
| Rate for Payer: BCBS MT CHIP |
$176.40
|
| Rate for Payer: BCBS MT Closed Plan Network |
$186.20
|
| Rate for Payer: BCBS MT HealthLink |
$176.40
|
| Rate for Payer: BCBS MT Medicare |
$176.40
|
| Rate for Payer: BCBS MT POS |
$186.20
|
| Rate for Payer: BCBS MT Traditional |
$196.00
|
| Rate for Payer: Cash Price |
$176.40
|
| Rate for Payer: Cigna Commercial |
$186.20
|
| Rate for Payer: Cigna Medicare |
$176.40
|
| Rate for Payer: Medicaid All Medicaid |
$180.32
|
| Rate for Payer: Medicare All Medicare |
$137.20
|
| Rate for Payer: Monida Allegiance |
$186.20
|
| Rate for Payer: Monida First Choice Health |
$190.12
|
| Rate for Payer: Monida Montana Health Co-op |
$186.20
|
| Rate for Payer: Monida PacificSource |
$186.20
|
|
|
KNEE WRAP HINGED MD
|
Facility
|
OP
|
$196.00
|
|
| Hospital Charge Code |
2893373
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$137.20 |
| Max. Negotiated Rate |
$196.00 |
| Rate for Payer: Aetna Commercial |
$186.20
|
| Rate for Payer: Aetna Medicare |
$176.40
|
| Rate for Payer: BCBS MT CHIP |
$176.40
|
| Rate for Payer: BCBS MT Closed Plan Network |
$186.20
|
| Rate for Payer: BCBS MT HealthLink |
$176.40
|
| Rate for Payer: BCBS MT Medicare |
$176.40
|
| Rate for Payer: BCBS MT POS |
$186.20
|
| Rate for Payer: BCBS MT Traditional |
$196.00
|
| Rate for Payer: Cash Price |
$176.40
|
| Rate for Payer: Cigna Commercial |
$186.20
|
| Rate for Payer: Cigna Medicare |
$176.40
|
| Rate for Payer: Medicaid All Medicaid |
$180.32
|
| Rate for Payer: Medicare All Medicare |
$137.20
|
| Rate for Payer: Monida Allegiance |
$186.20
|
| Rate for Payer: Monida First Choice Health |
$190.12
|
| Rate for Payer: Monida Montana Health Co-op |
$186.20
|
| Rate for Payer: Monida PacificSource |
$186.20
|
|
|
KNEE WRAP HINGED MD
|
Facility
|
IP
|
$196.00
|
|
| Hospital Charge Code |
2893373
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$137.20 |
| Max. Negotiated Rate |
$196.00 |
| Rate for Payer: Aetna Commercial |
$186.20
|
| Rate for Payer: Aetna Medicare |
$176.40
|
| Rate for Payer: BCBS MT CHIP |
$176.40
|
| Rate for Payer: BCBS MT Closed Plan Network |
$186.20
|
| Rate for Payer: BCBS MT HealthLink |
$176.40
|
| Rate for Payer: BCBS MT Medicare |
$176.40
|
| Rate for Payer: BCBS MT POS |
$186.20
|
| Rate for Payer: BCBS MT Traditional |
$196.00
|
| Rate for Payer: Cash Price |
$176.40
|
| Rate for Payer: Cigna Commercial |
$186.20
|
| Rate for Payer: Cigna Medicare |
$176.40
|
| Rate for Payer: Medicaid All Medicaid |
$180.32
|
| Rate for Payer: Medicare All Medicare |
$137.20
|
| Rate for Payer: Monida Allegiance |
$186.20
|
| Rate for Payer: Monida First Choice Health |
$190.12
|
| Rate for Payer: Monida Montana Health Co-op |
$186.20
|
| Rate for Payer: Monida PacificSource |
$186.20
|
|
|
KNEE WRAP HINGED SM
|
Facility
|
IP
|
$196.00
|
|
| Hospital Charge Code |
2893372
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$137.20 |
| Max. Negotiated Rate |
$196.00 |
| Rate for Payer: Aetna Commercial |
$186.20
|
| Rate for Payer: Aetna Medicare |
$176.40
|
| Rate for Payer: BCBS MT CHIP |
$176.40
|
| Rate for Payer: BCBS MT Closed Plan Network |
$186.20
|
| Rate for Payer: BCBS MT HealthLink |
$176.40
|
| Rate for Payer: BCBS MT Medicare |
$176.40
|
| Rate for Payer: BCBS MT POS |
$186.20
|
| Rate for Payer: BCBS MT Traditional |
$196.00
|
| Rate for Payer: Cash Price |
$176.40
|
| Rate for Payer: Cigna Commercial |
$186.20
|
| Rate for Payer: Cigna Medicare |
$176.40
|
| Rate for Payer: Medicaid All Medicaid |
$180.32
|
| Rate for Payer: Medicare All Medicare |
$137.20
|
| Rate for Payer: Monida Allegiance |
$186.20
|
| Rate for Payer: Monida First Choice Health |
$190.12
|
| Rate for Payer: Monida Montana Health Co-op |
$186.20
|
| Rate for Payer: Monida PacificSource |
$186.20
|
|
|
KNEE WRAP HINGED SM
|
Facility
|
OP
|
$196.00
|
|
| Hospital Charge Code |
2893372
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$137.20 |
| Max. Negotiated Rate |
$196.00 |
| Rate for Payer: Aetna Commercial |
$186.20
|
| Rate for Payer: Aetna Medicare |
$176.40
|
| Rate for Payer: BCBS MT CHIP |
$176.40
|
| Rate for Payer: BCBS MT Closed Plan Network |
$186.20
|
| Rate for Payer: BCBS MT HealthLink |
$176.40
|
| Rate for Payer: BCBS MT Medicare |
$176.40
|
| Rate for Payer: BCBS MT POS |
$186.20
|
| Rate for Payer: BCBS MT Traditional |
$196.00
|
| Rate for Payer: Cash Price |
$176.40
|
| Rate for Payer: Cigna Commercial |
$186.20
|
| Rate for Payer: Cigna Medicare |
$176.40
|
| Rate for Payer: Medicaid All Medicaid |
$180.32
|
| Rate for Payer: Medicare All Medicare |
$137.20
|
| Rate for Payer: Monida Allegiance |
$186.20
|
| Rate for Payer: Monida First Choice Health |
$190.12
|
| Rate for Payer: Monida Montana Health Co-op |
$186.20
|
| Rate for Payer: Monida PacificSource |
$186.20
|
|
|
KNEE WRAP HINGED XL
|
Facility
|
OP
|
$196.00
|
|
| Hospital Charge Code |
2893375
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$137.20 |
| Max. Negotiated Rate |
$196.00 |
| Rate for Payer: Aetna Commercial |
$186.20
|
| Rate for Payer: Aetna Medicare |
$176.40
|
| Rate for Payer: BCBS MT CHIP |
$176.40
|
| Rate for Payer: BCBS MT Closed Plan Network |
$186.20
|
| Rate for Payer: BCBS MT HealthLink |
$176.40
|
| Rate for Payer: BCBS MT Medicare |
$176.40
|
| Rate for Payer: BCBS MT POS |
$186.20
|
| Rate for Payer: BCBS MT Traditional |
$196.00
|
| Rate for Payer: Cash Price |
$176.40
|
| Rate for Payer: Cigna Commercial |
$186.20
|
| Rate for Payer: Cigna Medicare |
$176.40
|
| Rate for Payer: Medicaid All Medicaid |
$180.32
|
| Rate for Payer: Medicare All Medicare |
$137.20
|
| Rate for Payer: Monida Allegiance |
$186.20
|
| Rate for Payer: Monida First Choice Health |
$190.12
|
| Rate for Payer: Monida Montana Health Co-op |
$186.20
|
| Rate for Payer: Monida PacificSource |
$186.20
|
|
|
KNEE WRAP HINGED XL
|
Facility
|
IP
|
$196.00
|
|
| Hospital Charge Code |
2893375
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$137.20 |
| Max. Negotiated Rate |
$196.00 |
| Rate for Payer: Aetna Commercial |
$186.20
|
| Rate for Payer: Aetna Medicare |
$176.40
|
| Rate for Payer: BCBS MT CHIP |
$176.40
|
| Rate for Payer: BCBS MT Closed Plan Network |
$186.20
|
| Rate for Payer: BCBS MT HealthLink |
$176.40
|
| Rate for Payer: BCBS MT Medicare |
$176.40
|
| Rate for Payer: BCBS MT POS |
$186.20
|
| Rate for Payer: BCBS MT Traditional |
$196.00
|
| Rate for Payer: Cash Price |
$176.40
|
| Rate for Payer: Cigna Commercial |
$186.20
|
| Rate for Payer: Cigna Medicare |
$176.40
|
| Rate for Payer: Medicaid All Medicaid |
$180.32
|
| Rate for Payer: Medicare All Medicare |
$137.20
|
| Rate for Payer: Monida Allegiance |
$186.20
|
| Rate for Payer: Monida First Choice Health |
$190.12
|
| Rate for Payer: Monida Montana Health Co-op |
$186.20
|
| Rate for Payer: Monida PacificSource |
$186.20
|
|
|
KOH PREP: SKIN, HAIR, OR NAILS
|
Facility
|
OP
|
$58.00
|
|
|
Service Code
|
CPT 87220
|
| Hospital Charge Code |
4087220
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$40.60 |
| Max. Negotiated Rate |
$58.00 |
| Rate for Payer: Aetna Commercial |
$55.10
|
| Rate for Payer: Aetna Medicare |
$52.20
|
| Rate for Payer: BCBS MT CHIP |
$52.20
|
| Rate for Payer: BCBS MT Closed Plan Network |
$55.10
|
| Rate for Payer: BCBS MT HealthLink |
$52.20
|
| Rate for Payer: BCBS MT Medicare |
$52.20
|
| Rate for Payer: BCBS MT POS |
$55.10
|
| Rate for Payer: BCBS MT Traditional |
$58.00
|
| Rate for Payer: Cash Price |
$52.20
|
| Rate for Payer: Cigna Commercial |
$55.10
|
| Rate for Payer: Cigna Medicare |
$52.20
|
| Rate for Payer: Medicaid All Medicaid |
$53.36
|
| Rate for Payer: Medicare All Medicare |
$40.60
|
| Rate for Payer: Monida Allegiance |
$55.10
|
| Rate for Payer: Monida First Choice Health |
$56.26
|
| Rate for Payer: Monida Montana Health Co-op |
$55.10
|
| Rate for Payer: Monida PacificSource |
$55.10
|
|
|
KOH PREP: SKIN, HAIR, OR NAILS
|
Facility
|
IP
|
$58.00
|
|
|
Service Code
|
CPT 87220
|
| Hospital Charge Code |
4087220
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$40.60 |
| Max. Negotiated Rate |
$58.00 |
| Rate for Payer: Aetna Commercial |
$55.10
|
| Rate for Payer: Aetna Medicare |
$52.20
|
| Rate for Payer: BCBS MT CHIP |
$52.20
|
| Rate for Payer: BCBS MT Closed Plan Network |
$55.10
|
| Rate for Payer: BCBS MT HealthLink |
$52.20
|
| Rate for Payer: BCBS MT Medicare |
$52.20
|
| Rate for Payer: BCBS MT POS |
$55.10
|
| Rate for Payer: BCBS MT Traditional |
$58.00
|
| Rate for Payer: Cash Price |
$52.20
|
| Rate for Payer: Cigna Commercial |
$55.10
|
| Rate for Payer: Cigna Medicare |
$52.20
|
| Rate for Payer: Medicaid All Medicaid |
$53.36
|
| Rate for Payer: Medicare All Medicare |
$40.60
|
| Rate for Payer: Monida Allegiance |
$55.10
|
| Rate for Payer: Monida First Choice Health |
$56.26
|
| Rate for Payer: Monida Montana Health Co-op |
$55.10
|
| Rate for Payer: Monida PacificSource |
$55.10
|
|
|
LAB 24HR URINE CYSTINE
|
Facility
|
IP
|
$73.00
|
|
|
Service Code
|
CPT 82131
|
| Hospital Charge Code |
4082131
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$51.10 |
| Max. Negotiated Rate |
$73.00 |
| Rate for Payer: Aetna Commercial |
$69.35
|
| Rate for Payer: Aetna Medicare |
$65.70
|
| Rate for Payer: BCBS MT CHIP |
$65.70
|
| Rate for Payer: BCBS MT Closed Plan Network |
$69.35
|
| Rate for Payer: BCBS MT HealthLink |
$65.70
|
| Rate for Payer: BCBS MT Medicare |
$65.70
|
| Rate for Payer: BCBS MT POS |
$69.35
|
| Rate for Payer: BCBS MT Traditional |
$73.00
|
| Rate for Payer: Cash Price |
$65.70
|
| Rate for Payer: Cigna Commercial |
$69.35
|
| Rate for Payer: Cigna Medicare |
$65.70
|
| Rate for Payer: Medicaid All Medicaid |
$67.16
|
| Rate for Payer: Medicare All Medicare |
$51.10
|
| Rate for Payer: Monida Allegiance |
$69.35
|
| Rate for Payer: Monida First Choice Health |
$70.81
|
| Rate for Payer: Monida Montana Health Co-op |
$69.35
|
| Rate for Payer: Monida PacificSource |
$69.35
|
|
