|
SPLASHCAP (NON STOCK BSME)
|
Facility
|
OP
|
$5.00
|
|
| Hospital Charge Code |
80040162
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$3.50 |
| Max. Negotiated Rate |
$5.00 |
| Rate for Payer: Aetna Commercial |
$4.75
|
| Rate for Payer: Aetna Medicare |
$4.50
|
| Rate for Payer: BCBS MT CHIP |
$4.50
|
| Rate for Payer: BCBS MT Closed Plan Network |
$4.75
|
| Rate for Payer: BCBS MT HealthLink |
$4.50
|
| Rate for Payer: BCBS MT Medicare |
$4.50
|
| Rate for Payer: BCBS MT POS |
$4.75
|
| Rate for Payer: BCBS MT Traditional |
$5.00
|
| Rate for Payer: Cash Price |
$4.50
|
| Rate for Payer: Cigna Commercial |
$4.75
|
| Rate for Payer: Cigna Medicare |
$4.50
|
| Rate for Payer: Medicaid All Medicaid |
$4.60
|
| Rate for Payer: Medicare All Medicare |
$3.50
|
| Rate for Payer: Monida Allegiance |
$4.75
|
| Rate for Payer: Monida First Choice Health |
$4.85
|
| Rate for Payer: Monida Montana Health Co-op |
$4.75
|
| Rate for Payer: Monida PacificSource |
$4.75
|
|
|
SPLASHCAP (NON STOCK BSME)
|
Facility
|
IP
|
$5.00
|
|
| Hospital Charge Code |
80040162
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$3.50 |
| Max. Negotiated Rate |
$5.00 |
| Rate for Payer: Aetna Commercial |
$4.75
|
| Rate for Payer: Aetna Medicare |
$4.50
|
| Rate for Payer: BCBS MT CHIP |
$4.50
|
| Rate for Payer: BCBS MT Closed Plan Network |
$4.75
|
| Rate for Payer: BCBS MT HealthLink |
$4.50
|
| Rate for Payer: BCBS MT Medicare |
$4.50
|
| Rate for Payer: BCBS MT POS |
$4.75
|
| Rate for Payer: BCBS MT Traditional |
$5.00
|
| Rate for Payer: Cash Price |
$4.50
|
| Rate for Payer: Cigna Commercial |
$4.75
|
| Rate for Payer: Cigna Medicare |
$4.50
|
| Rate for Payer: Medicaid All Medicaid |
$4.60
|
| Rate for Payer: Medicare All Medicare |
$3.50
|
| Rate for Payer: Monida Allegiance |
$4.75
|
| Rate for Payer: Monida First Choice Health |
$4.85
|
| Rate for Payer: Monida Montana Health Co-op |
$4.75
|
| Rate for Payer: Monida PacificSource |
$4.75
|
|
|
SPLINT COLLES LT/LG PADDED
|
Facility
|
OP
|
$22.00
|
|
| Hospital Charge Code |
2893520
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$15.40 |
| Max. Negotiated Rate |
$22.00 |
| Rate for Payer: Aetna Commercial |
$20.90
|
| Rate for Payer: Aetna Medicare |
$19.80
|
| Rate for Payer: BCBS MT CHIP |
$19.80
|
| Rate for Payer: BCBS MT Closed Plan Network |
$20.90
|
| Rate for Payer: BCBS MT HealthLink |
$19.80
|
| Rate for Payer: BCBS MT Medicare |
$19.80
|
| Rate for Payer: BCBS MT POS |
$20.90
|
| Rate for Payer: BCBS MT Traditional |
$22.00
|
| Rate for Payer: Cash Price |
$19.80
|
| Rate for Payer: Cigna Commercial |
$20.90
|
| Rate for Payer: Cigna Medicare |
$19.80
|
| Rate for Payer: Medicaid All Medicaid |
$20.24
|
| Rate for Payer: Medicare All Medicare |
$15.40
|
| Rate for Payer: Monida Allegiance |
$20.90
|
| Rate for Payer: Monida First Choice Health |
$21.34
|
| Rate for Payer: Monida Montana Health Co-op |
$20.90
|
| Rate for Payer: Monida PacificSource |
$20.90
|
|
|
SPLINT COLLES LT/LG PADDED
|
Facility
|
IP
|
$22.00
|
|
| Hospital Charge Code |
2893520
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$15.40 |
| Max. Negotiated Rate |
$22.00 |
| Rate for Payer: Aetna Commercial |
$20.90
|
| Rate for Payer: Aetna Medicare |
$19.80
|
| Rate for Payer: BCBS MT CHIP |
$19.80
|
| Rate for Payer: BCBS MT Closed Plan Network |
$20.90
|
| Rate for Payer: BCBS MT HealthLink |
$19.80
|
| Rate for Payer: BCBS MT Medicare |
$19.80
|
| Rate for Payer: BCBS MT POS |
$20.90
|
| Rate for Payer: BCBS MT Traditional |
$22.00
|
| Rate for Payer: Cash Price |
$19.80
|
| Rate for Payer: Cigna Commercial |
$20.90
|
| Rate for Payer: Cigna Medicare |
$19.80
|
| Rate for Payer: Medicaid All Medicaid |
$20.24
|
| Rate for Payer: Medicare All Medicare |
$15.40
|
| Rate for Payer: Monida Allegiance |
$20.90
|
| Rate for Payer: Monida First Choice Health |
$21.34
|
| Rate for Payer: Monida Montana Health Co-op |
$20.90
|
| Rate for Payer: Monida PacificSource |
$20.90
|
|
|
SPLINT COLLES LT/MED PADDED
|
Facility
|
IP
|
$22.00
|
|
| Hospital Charge Code |
2893519
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$15.40 |
| Max. Negotiated Rate |
$22.00 |
| Rate for Payer: Aetna Commercial |
$20.90
|
| Rate for Payer: Aetna Medicare |
$19.80
|
| Rate for Payer: BCBS MT CHIP |
$19.80
|
| Rate for Payer: BCBS MT Closed Plan Network |
$20.90
|
| Rate for Payer: BCBS MT HealthLink |
$19.80
|
| Rate for Payer: BCBS MT Medicare |
$19.80
|
| Rate for Payer: BCBS MT POS |
$20.90
|
| Rate for Payer: BCBS MT Traditional |
$22.00
|
| Rate for Payer: Cash Price |
$19.80
|
| Rate for Payer: Cigna Commercial |
$20.90
|
| Rate for Payer: Cigna Medicare |
$19.80
|
| Rate for Payer: Medicaid All Medicaid |
$20.24
|
| Rate for Payer: Medicare All Medicare |
$15.40
|
| Rate for Payer: Monida Allegiance |
$20.90
|
| Rate for Payer: Monida First Choice Health |
$21.34
|
| Rate for Payer: Monida Montana Health Co-op |
$20.90
|
| Rate for Payer: Monida PacificSource |
$20.90
|
|
|
SPLINT COLLES LT/MED PADDED
|
Facility
|
OP
|
$22.00
|
|
| Hospital Charge Code |
2893519
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$15.40 |
| Max. Negotiated Rate |
$22.00 |
| Rate for Payer: Aetna Commercial |
$20.90
|
| Rate for Payer: Aetna Medicare |
$19.80
|
| Rate for Payer: BCBS MT CHIP |
$19.80
|
| Rate for Payer: BCBS MT Closed Plan Network |
$20.90
|
| Rate for Payer: BCBS MT HealthLink |
$19.80
|
| Rate for Payer: BCBS MT Medicare |
$19.80
|
| Rate for Payer: BCBS MT POS |
$20.90
|
| Rate for Payer: BCBS MT Traditional |
$22.00
|
| Rate for Payer: Cash Price |
$19.80
|
| Rate for Payer: Cigna Commercial |
$20.90
|
| Rate for Payer: Cigna Medicare |
$19.80
|
| Rate for Payer: Medicaid All Medicaid |
$20.24
|
| Rate for Payer: Medicare All Medicare |
$15.40
|
| Rate for Payer: Monida Allegiance |
$20.90
|
| Rate for Payer: Monida First Choice Health |
$21.34
|
| Rate for Payer: Monida Montana Health Co-op |
$20.90
|
| Rate for Payer: Monida PacificSource |
$20.90
|
|
|
SPLINT COLLES LT/SM PADDED
|
Facility
|
OP
|
$22.00
|
|
| Hospital Charge Code |
2893518
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$15.40 |
| Max. Negotiated Rate |
$22.00 |
| Rate for Payer: Aetna Commercial |
$20.90
|
| Rate for Payer: Aetna Medicare |
$19.80
|
| Rate for Payer: BCBS MT CHIP |
$19.80
|
| Rate for Payer: BCBS MT Closed Plan Network |
$20.90
|
| Rate for Payer: BCBS MT HealthLink |
$19.80
|
| Rate for Payer: BCBS MT Medicare |
$19.80
|
| Rate for Payer: BCBS MT POS |
$20.90
|
| Rate for Payer: BCBS MT Traditional |
$22.00
|
| Rate for Payer: Cash Price |
$19.80
|
| Rate for Payer: Cigna Commercial |
$20.90
|
| Rate for Payer: Cigna Medicare |
$19.80
|
| Rate for Payer: Medicaid All Medicaid |
$20.24
|
| Rate for Payer: Medicare All Medicare |
$15.40
|
| Rate for Payer: Monida Allegiance |
$20.90
|
| Rate for Payer: Monida First Choice Health |
$21.34
|
| Rate for Payer: Monida Montana Health Co-op |
$20.90
|
| Rate for Payer: Monida PacificSource |
$20.90
|
|
|
SPLINT COLLES LT/SM PADDED
|
Facility
|
IP
|
$22.00
|
|
| Hospital Charge Code |
2893518
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$15.40 |
| Max. Negotiated Rate |
$22.00 |
| Rate for Payer: Aetna Commercial |
$20.90
|
| Rate for Payer: Aetna Medicare |
$19.80
|
| Rate for Payer: BCBS MT CHIP |
$19.80
|
| Rate for Payer: BCBS MT Closed Plan Network |
$20.90
|
| Rate for Payer: BCBS MT HealthLink |
$19.80
|
| Rate for Payer: BCBS MT Medicare |
$19.80
|
| Rate for Payer: BCBS MT POS |
$20.90
|
| Rate for Payer: BCBS MT Traditional |
$22.00
|
| Rate for Payer: Cash Price |
$19.80
|
| Rate for Payer: Cigna Commercial |
$20.90
|
| Rate for Payer: Cigna Medicare |
$19.80
|
| Rate for Payer: Medicaid All Medicaid |
$20.24
|
| Rate for Payer: Medicare All Medicare |
$15.40
|
| Rate for Payer: Monida Allegiance |
$20.90
|
| Rate for Payer: Monida First Choice Health |
$21.34
|
| Rate for Payer: Monida Montana Health Co-op |
$20.90
|
| Rate for Payer: Monida PacificSource |
$20.90
|
|
|
SPLINT COLLES LT/XSM
|
Facility
|
IP
|
$25.00
|
|
|
Service Code
|
HCPCS A4570
|
| Hospital Charge Code |
2830177
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$17.50 |
| Max. Negotiated Rate |
$25.00 |
| Rate for Payer: Aetna Commercial |
$23.75
|
| Rate for Payer: Aetna Medicare |
$22.50
|
| Rate for Payer: BCBS MT CHIP |
$22.50
|
| Rate for Payer: BCBS MT Closed Plan Network |
$23.75
|
| Rate for Payer: BCBS MT HealthLink |
$22.50
|
| Rate for Payer: BCBS MT Medicare |
$22.50
|
| Rate for Payer: BCBS MT POS |
$23.75
|
| Rate for Payer: BCBS MT Traditional |
$25.00
|
| Rate for Payer: Cash Price |
$22.50
|
| Rate for Payer: Cigna Commercial |
$23.75
|
| Rate for Payer: Cigna Medicare |
$22.50
|
| Rate for Payer: Medicaid All Medicaid |
$23.00
|
| Rate for Payer: Medicare All Medicare |
$17.50
|
| Rate for Payer: Monida Allegiance |
$23.75
|
| Rate for Payer: Monida First Choice Health |
$24.25
|
| Rate for Payer: Monida Montana Health Co-op |
$23.75
|
| Rate for Payer: Monida PacificSource |
$23.75
|
|
|
SPLINT COLLES LT/XSM
|
Facility
|
OP
|
$25.00
|
|
|
Service Code
|
HCPCS A4570
|
| Hospital Charge Code |
2830177
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$17.50 |
| Max. Negotiated Rate |
$25.00 |
| Rate for Payer: Aetna Commercial |
$23.75
|
| Rate for Payer: Aetna Medicare |
$22.50
|
| Rate for Payer: BCBS MT CHIP |
$22.50
|
| Rate for Payer: BCBS MT Closed Plan Network |
$23.75
|
| Rate for Payer: BCBS MT HealthLink |
$22.50
|
| Rate for Payer: BCBS MT Medicare |
$22.50
|
| Rate for Payer: BCBS MT POS |
$23.75
|
| Rate for Payer: BCBS MT Traditional |
$25.00
|
| Rate for Payer: Cash Price |
$22.50
|
| Rate for Payer: Cigna Commercial |
$23.75
|
| Rate for Payer: Cigna Medicare |
$22.50
|
| Rate for Payer: Medicaid All Medicaid |
$23.00
|
| Rate for Payer: Medicare All Medicare |
$17.50
|
| Rate for Payer: Monida Allegiance |
$23.75
|
| Rate for Payer: Monida First Choice Health |
$24.25
|
| Rate for Payer: Monida Montana Health Co-op |
$23.75
|
| Rate for Payer: Monida PacificSource |
$23.75
|
|
|
SPLINT COLLES RT/LG PADDED
|
Facility
|
OP
|
$22.00
|
|
| Hospital Charge Code |
2893524
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$15.40 |
| Max. Negotiated Rate |
$22.00 |
| Rate for Payer: Aetna Commercial |
$20.90
|
| Rate for Payer: Aetna Medicare |
$19.80
|
| Rate for Payer: BCBS MT CHIP |
$19.80
|
| Rate for Payer: BCBS MT Closed Plan Network |
$20.90
|
| Rate for Payer: BCBS MT HealthLink |
$19.80
|
| Rate for Payer: BCBS MT Medicare |
$19.80
|
| Rate for Payer: BCBS MT POS |
$20.90
|
| Rate for Payer: BCBS MT Traditional |
$22.00
|
| Rate for Payer: Cash Price |
$19.80
|
| Rate for Payer: Cigna Commercial |
$20.90
|
| Rate for Payer: Cigna Medicare |
$19.80
|
| Rate for Payer: Medicaid All Medicaid |
$20.24
|
| Rate for Payer: Medicare All Medicare |
$15.40
|
| Rate for Payer: Monida Allegiance |
$20.90
|
| Rate for Payer: Monida First Choice Health |
$21.34
|
| Rate for Payer: Monida Montana Health Co-op |
$20.90
|
| Rate for Payer: Monida PacificSource |
$20.90
|
|
|
SPLINT COLLES RT/LG PADDED
|
Facility
|
IP
|
$22.00
|
|
| Hospital Charge Code |
2893524
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$15.40 |
| Max. Negotiated Rate |
$22.00 |
| Rate for Payer: Aetna Commercial |
$20.90
|
| Rate for Payer: Aetna Medicare |
$19.80
|
| Rate for Payer: BCBS MT CHIP |
$19.80
|
| Rate for Payer: BCBS MT Closed Plan Network |
$20.90
|
| Rate for Payer: BCBS MT HealthLink |
$19.80
|
| Rate for Payer: BCBS MT Medicare |
$19.80
|
| Rate for Payer: BCBS MT POS |
$20.90
|
| Rate for Payer: BCBS MT Traditional |
$22.00
|
| Rate for Payer: Cash Price |
$19.80
|
| Rate for Payer: Cigna Commercial |
$20.90
|
| Rate for Payer: Cigna Medicare |
$19.80
|
| Rate for Payer: Medicaid All Medicaid |
$20.24
|
| Rate for Payer: Medicare All Medicare |
$15.40
|
| Rate for Payer: Monida Allegiance |
$20.90
|
| Rate for Payer: Monida First Choice Health |
$21.34
|
| Rate for Payer: Monida Montana Health Co-op |
$20.90
|
| Rate for Payer: Monida PacificSource |
$20.90
|
|
|
SPLINT COLLES RT/MED. PADDED
|
Facility
|
OP
|
$22.00
|
|
| Hospital Charge Code |
2893523
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$15.40 |
| Max. Negotiated Rate |
$22.00 |
| Rate for Payer: Aetna Commercial |
$20.90
|
| Rate for Payer: Aetna Medicare |
$19.80
|
| Rate for Payer: BCBS MT CHIP |
$19.80
|
| Rate for Payer: BCBS MT Closed Plan Network |
$20.90
|
| Rate for Payer: BCBS MT HealthLink |
$19.80
|
| Rate for Payer: BCBS MT Medicare |
$19.80
|
| Rate for Payer: BCBS MT POS |
$20.90
|
| Rate for Payer: BCBS MT Traditional |
$22.00
|
| Rate for Payer: Cash Price |
$19.80
|
| Rate for Payer: Cigna Commercial |
$20.90
|
| Rate for Payer: Cigna Medicare |
$19.80
|
| Rate for Payer: Medicaid All Medicaid |
$20.24
|
| Rate for Payer: Medicare All Medicare |
$15.40
|
| Rate for Payer: Monida Allegiance |
$20.90
|
| Rate for Payer: Monida First Choice Health |
$21.34
|
| Rate for Payer: Monida Montana Health Co-op |
$20.90
|
| Rate for Payer: Monida PacificSource |
$20.90
|
|
|
SPLINT COLLES RT/MED. PADDED
|
Facility
|
IP
|
$22.00
|
|
| Hospital Charge Code |
2893523
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$15.40 |
| Max. Negotiated Rate |
$22.00 |
| Rate for Payer: Aetna Commercial |
$20.90
|
| Rate for Payer: Aetna Medicare |
$19.80
|
| Rate for Payer: BCBS MT CHIP |
$19.80
|
| Rate for Payer: BCBS MT Closed Plan Network |
$20.90
|
| Rate for Payer: BCBS MT HealthLink |
$19.80
|
| Rate for Payer: BCBS MT Medicare |
$19.80
|
| Rate for Payer: BCBS MT POS |
$20.90
|
| Rate for Payer: BCBS MT Traditional |
$22.00
|
| Rate for Payer: Cash Price |
$19.80
|
| Rate for Payer: Cigna Commercial |
$20.90
|
| Rate for Payer: Cigna Medicare |
$19.80
|
| Rate for Payer: Medicaid All Medicaid |
$20.24
|
| Rate for Payer: Medicare All Medicare |
$15.40
|
| Rate for Payer: Monida Allegiance |
$20.90
|
| Rate for Payer: Monida First Choice Health |
$21.34
|
| Rate for Payer: Monida Montana Health Co-op |
$20.90
|
| Rate for Payer: Monida PacificSource |
$20.90
|
|
|
SPLINT COLLES RT/SM PADDED
|
Facility
|
OP
|
$22.00
|
|
| Hospital Charge Code |
2893522
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$15.40 |
| Max. Negotiated Rate |
$22.00 |
| Rate for Payer: Aetna Commercial |
$20.90
|
| Rate for Payer: Aetna Medicare |
$19.80
|
| Rate for Payer: BCBS MT CHIP |
$19.80
|
| Rate for Payer: BCBS MT Closed Plan Network |
$20.90
|
| Rate for Payer: BCBS MT HealthLink |
$19.80
|
| Rate for Payer: BCBS MT Medicare |
$19.80
|
| Rate for Payer: BCBS MT POS |
$20.90
|
| Rate for Payer: BCBS MT Traditional |
$22.00
|
| Rate for Payer: Cash Price |
$19.80
|
| Rate for Payer: Cigna Commercial |
$20.90
|
| Rate for Payer: Cigna Medicare |
$19.80
|
| Rate for Payer: Medicaid All Medicaid |
$20.24
|
| Rate for Payer: Medicare All Medicare |
$15.40
|
| Rate for Payer: Monida Allegiance |
$20.90
|
| Rate for Payer: Monida First Choice Health |
$21.34
|
| Rate for Payer: Monida Montana Health Co-op |
$20.90
|
| Rate for Payer: Monida PacificSource |
$20.90
|
|
|
SPLINT COLLES RT/SM PADDED
|
Facility
|
IP
|
$22.00
|
|
| Hospital Charge Code |
2893522
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$15.40 |
| Max. Negotiated Rate |
$22.00 |
| Rate for Payer: Aetna Commercial |
$20.90
|
| Rate for Payer: Aetna Medicare |
$19.80
|
| Rate for Payer: BCBS MT CHIP |
$19.80
|
| Rate for Payer: BCBS MT Closed Plan Network |
$20.90
|
| Rate for Payer: BCBS MT HealthLink |
$19.80
|
| Rate for Payer: BCBS MT Medicare |
$19.80
|
| Rate for Payer: BCBS MT POS |
$20.90
|
| Rate for Payer: BCBS MT Traditional |
$22.00
|
| Rate for Payer: Cash Price |
$19.80
|
| Rate for Payer: Cigna Commercial |
$20.90
|
| Rate for Payer: Cigna Medicare |
$19.80
|
| Rate for Payer: Medicaid All Medicaid |
$20.24
|
| Rate for Payer: Medicare All Medicare |
$15.40
|
| Rate for Payer: Monida Allegiance |
$20.90
|
| Rate for Payer: Monida First Choice Health |
$21.34
|
| Rate for Payer: Monida Montana Health Co-op |
$20.90
|
| Rate for Payer: Monida PacificSource |
$20.90
|
|
|
SPLINT COLLES RT/XSM PADDED
|
Facility
|
IP
|
$22.00
|
|
| Hospital Charge Code |
2893521
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$15.40 |
| Max. Negotiated Rate |
$22.00 |
| Rate for Payer: Aetna Commercial |
$20.90
|
| Rate for Payer: Aetna Medicare |
$19.80
|
| Rate for Payer: BCBS MT CHIP |
$19.80
|
| Rate for Payer: BCBS MT Closed Plan Network |
$20.90
|
| Rate for Payer: BCBS MT HealthLink |
$19.80
|
| Rate for Payer: BCBS MT Medicare |
$19.80
|
| Rate for Payer: BCBS MT POS |
$20.90
|
| Rate for Payer: BCBS MT Traditional |
$22.00
|
| Rate for Payer: Cash Price |
$19.80
|
| Rate for Payer: Cigna Commercial |
$20.90
|
| Rate for Payer: Cigna Medicare |
$19.80
|
| Rate for Payer: Medicaid All Medicaid |
$20.24
|
| Rate for Payer: Medicare All Medicare |
$15.40
|
| Rate for Payer: Monida Allegiance |
$20.90
|
| Rate for Payer: Monida First Choice Health |
$21.34
|
| Rate for Payer: Monida Montana Health Co-op |
$20.90
|
| Rate for Payer: Monida PacificSource |
$20.90
|
|
|
SPLINT COLLES RT/XSM PADDED
|
Facility
|
OP
|
$22.00
|
|
| Hospital Charge Code |
2893521
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$15.40 |
| Max. Negotiated Rate |
$22.00 |
| Rate for Payer: Aetna Commercial |
$20.90
|
| Rate for Payer: Aetna Medicare |
$19.80
|
| Rate for Payer: BCBS MT CHIP |
$19.80
|
| Rate for Payer: BCBS MT Closed Plan Network |
$20.90
|
| Rate for Payer: BCBS MT HealthLink |
$19.80
|
| Rate for Payer: BCBS MT Medicare |
$19.80
|
| Rate for Payer: BCBS MT POS |
$20.90
|
| Rate for Payer: BCBS MT Traditional |
$22.00
|
| Rate for Payer: Cash Price |
$19.80
|
| Rate for Payer: Cigna Commercial |
$20.90
|
| Rate for Payer: Cigna Medicare |
$19.80
|
| Rate for Payer: Medicaid All Medicaid |
$20.24
|
| Rate for Payer: Medicare All Medicare |
$15.40
|
| Rate for Payer: Monida Allegiance |
$20.90
|
| Rate for Payer: Monida First Choice Health |
$21.34
|
| Rate for Payer: Monida Montana Health Co-op |
$20.90
|
| Rate for Payer: Monida PacificSource |
$20.90
|
|
|
SPLINT LARGE
|
Facility
|
OP
|
$495.00
|
|
| Hospital Charge Code |
1050859
|
|
Hospital Revenue Code
|
230
|
| Min. Negotiated Rate |
$346.50 |
| Max. Negotiated Rate |
$495.00 |
| Rate for Payer: Aetna Commercial |
$470.25
|
| Rate for Payer: Aetna Medicare |
$445.50
|
| Rate for Payer: BCBS MT CHIP |
$445.50
|
| Rate for Payer: BCBS MT Closed Plan Network |
$470.25
|
| Rate for Payer: BCBS MT HealthLink |
$445.50
|
| Rate for Payer: BCBS MT Medicare |
$445.50
|
| Rate for Payer: BCBS MT POS |
$470.25
|
| Rate for Payer: BCBS MT Traditional |
$495.00
|
| Rate for Payer: Cash Price |
$445.50
|
| Rate for Payer: Cigna Commercial |
$470.25
|
| Rate for Payer: Cigna Medicare |
$445.50
|
| Rate for Payer: Medicaid All Medicaid |
$455.40
|
| Rate for Payer: Medicare All Medicare |
$346.50
|
| Rate for Payer: Monida Allegiance |
$470.25
|
| Rate for Payer: Monida First Choice Health |
$480.15
|
| Rate for Payer: Monida Montana Health Co-op |
$470.25
|
| Rate for Payer: Monida PacificSource |
$470.25
|
|
|
SPLINT LARGE
|
Facility
|
IP
|
$495.00
|
|
| Hospital Charge Code |
1050859
|
|
Hospital Revenue Code
|
230
|
| Min. Negotiated Rate |
$346.50 |
| Max. Negotiated Rate |
$495.00 |
| Rate for Payer: Aetna Commercial |
$470.25
|
| Rate for Payer: Aetna Medicare |
$445.50
|
| Rate for Payer: BCBS MT CHIP |
$445.50
|
| Rate for Payer: BCBS MT Closed Plan Network |
$470.25
|
| Rate for Payer: BCBS MT HealthLink |
$445.50
|
| Rate for Payer: BCBS MT Medicare |
$445.50
|
| Rate for Payer: BCBS MT POS |
$470.25
|
| Rate for Payer: BCBS MT Traditional |
$495.00
|
| Rate for Payer: Cash Price |
$445.50
|
| Rate for Payer: Cigna Commercial |
$470.25
|
| Rate for Payer: Cigna Medicare |
$445.50
|
| Rate for Payer: Medicaid All Medicaid |
$455.40
|
| Rate for Payer: Medicare All Medicare |
$346.50
|
| Rate for Payer: Monida Allegiance |
$470.25
|
| Rate for Payer: Monida First Choice Health |
$480.15
|
| Rate for Payer: Monida Montana Health Co-op |
$470.25
|
| Rate for Payer: Monida PacificSource |
$470.25
|
|
|
SPLINT WRIST/HAND
|
Facility
|
IP
|
$121.00
|
|
|
Service Code
|
HCPCS L3908
|
| Hospital Charge Code |
8003908
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$84.70 |
| Max. Negotiated Rate |
$121.00 |
| Rate for Payer: Aetna Commercial |
$114.95
|
| Rate for Payer: Aetna Medicare |
$108.90
|
| Rate for Payer: BCBS MT CHIP |
$108.90
|
| Rate for Payer: BCBS MT Closed Plan Network |
$114.95
|
| Rate for Payer: BCBS MT HealthLink |
$108.90
|
| Rate for Payer: BCBS MT Medicare |
$108.90
|
| Rate for Payer: BCBS MT POS |
$114.95
|
| Rate for Payer: BCBS MT Traditional |
$121.00
|
| Rate for Payer: Cash Price |
$108.90
|
| Rate for Payer: Cigna Commercial |
$114.95
|
| Rate for Payer: Cigna Medicare |
$108.90
|
| Rate for Payer: Medicaid All Medicaid |
$111.32
|
| Rate for Payer: Medicare All Medicare |
$84.70
|
| Rate for Payer: Monida Allegiance |
$114.95
|
| Rate for Payer: Monida First Choice Health |
$117.37
|
| Rate for Payer: Monida Montana Health Co-op |
$114.95
|
| Rate for Payer: Monida PacificSource |
$114.95
|
|
|
SPLINT WRIST/HAND
|
Facility
|
OP
|
$121.00
|
|
|
Service Code
|
HCPCS L3908
|
| Hospital Charge Code |
8003908
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$84.70 |
| Max. Negotiated Rate |
$121.00 |
| Rate for Payer: Aetna Commercial |
$114.95
|
| Rate for Payer: Aetna Medicare |
$108.90
|
| Rate for Payer: BCBS MT CHIP |
$108.90
|
| Rate for Payer: BCBS MT Closed Plan Network |
$114.95
|
| Rate for Payer: BCBS MT HealthLink |
$108.90
|
| Rate for Payer: BCBS MT Medicare |
$108.90
|
| Rate for Payer: BCBS MT POS |
$114.95
|
| Rate for Payer: BCBS MT Traditional |
$121.00
|
| Rate for Payer: Cash Price |
$108.90
|
| Rate for Payer: Cigna Commercial |
$114.95
|
| Rate for Payer: Cigna Medicare |
$108.90
|
| Rate for Payer: Medicaid All Medicaid |
$111.32
|
| Rate for Payer: Medicare All Medicare |
$84.70
|
| Rate for Payer: Monida Allegiance |
$114.95
|
| Rate for Payer: Monida First Choice Health |
$117.37
|
| Rate for Payer: Monida Montana Health Co-op |
$114.95
|
| Rate for Payer: Monida PacificSource |
$114.95
|
|
|
.SPUTUM CULTURE REFLEX
|
Facility
|
OP
|
$64.00
|
|
|
Service Code
|
HCPCS 87070
|
| Hospital Charge Code |
4070704
|
|
Hospital Revenue Code
|
306
|
| 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
|
|
|
.SPUTUM CULTURE REFLEX
|
Facility
|
IP
|
$64.00
|
|
|
Service Code
|
HCPCS 87070
|
| Hospital Charge Code |
4070704
|
|
Hospital Revenue Code
|
306
|
| 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
|
|
|
SS-A/RO ANTIBODIES, IGG (012682)
|
Facility
|
IP
|
$114.00
|
|
|
Service Code
|
HCPCS 86235
|
| Hospital Charge Code |
4000066
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$79.80 |
| Max. Negotiated Rate |
$114.00 |
| Rate for Payer: Aetna Commercial |
$108.30
|
| Rate for Payer: Aetna Medicare |
$102.60
|
| Rate for Payer: BCBS MT CHIP |
$102.60
|
| Rate for Payer: BCBS MT Closed Plan Network |
$108.30
|
| Rate for Payer: BCBS MT HealthLink |
$102.60
|
| Rate for Payer: BCBS MT Medicare |
$102.60
|
| Rate for Payer: BCBS MT POS |
$108.30
|
| Rate for Payer: BCBS MT Traditional |
$114.00
|
| Rate for Payer: Cash Price |
$102.60
|
| Rate for Payer: Cigna Commercial |
$108.30
|
| Rate for Payer: Cigna Medicare |
$102.60
|
| Rate for Payer: Medicaid All Medicaid |
$104.88
|
| Rate for Payer: Medicare All Medicare |
$79.80
|
| Rate for Payer: Monida Allegiance |
$108.30
|
| Rate for Payer: Monida First Choice Health |
$110.58
|
| Rate for Payer: Monida Montana Health Co-op |
$108.30
|
| Rate for Payer: Monida PacificSource |
$108.30
|
|
