|
CAST PADDING 3''
|
Facility
|
IP
|
$30.00
|
|
|
Service Code
|
HCPCS A4590
|
| Hospital Charge Code |
80030070
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$21.00 |
| Max. Negotiated Rate |
$30.00 |
| Rate for Payer: Aetna Commercial |
$28.50
|
| Rate for Payer: Aetna Medicare |
$27.00
|
| Rate for Payer: BCBS MT CHIP |
$27.00
|
| Rate for Payer: BCBS MT Closed Plan Network |
$28.50
|
| Rate for Payer: BCBS MT HealthLink |
$27.00
|
| Rate for Payer: BCBS MT Medicare |
$27.00
|
| Rate for Payer: BCBS MT POS |
$28.50
|
| Rate for Payer: BCBS MT Traditional |
$30.00
|
| Rate for Payer: Cash Price |
$27.00
|
| Rate for Payer: Cigna Commercial |
$28.50
|
| Rate for Payer: Cigna Medicare |
$27.00
|
| Rate for Payer: Medicaid All Medicaid |
$27.60
|
| Rate for Payer: Medicare All Medicare |
$21.00
|
| Rate for Payer: Monida Allegiance |
$28.50
|
| Rate for Payer: Monida First Choice Health |
$29.10
|
| Rate for Payer: Monida Montana Health Co-op |
$28.50
|
| Rate for Payer: Monida PacificSource |
$28.50
|
|
|
CAST PADDING 4''
|
Facility
|
OP
|
$35.00
|
|
|
Service Code
|
HCPCS A4590
|
| Hospital Charge Code |
80030072
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$24.50 |
| Max. Negotiated Rate |
$35.00 |
| Rate for Payer: Aetna Commercial |
$33.25
|
| Rate for Payer: Aetna Medicare |
$31.50
|
| Rate for Payer: BCBS MT CHIP |
$31.50
|
| Rate for Payer: BCBS MT Closed Plan Network |
$33.25
|
| Rate for Payer: BCBS MT HealthLink |
$31.50
|
| Rate for Payer: BCBS MT Medicare |
$31.50
|
| Rate for Payer: BCBS MT POS |
$33.25
|
| Rate for Payer: BCBS MT Traditional |
$35.00
|
| Rate for Payer: Cash Price |
$31.50
|
| Rate for Payer: Cigna Commercial |
$33.25
|
| Rate for Payer: Cigna Medicare |
$31.50
|
| Rate for Payer: Medicaid All Medicaid |
$32.20
|
| Rate for Payer: Medicare All Medicare |
$24.50
|
| Rate for Payer: Monida Allegiance |
$33.25
|
| Rate for Payer: Monida First Choice Health |
$33.95
|
| Rate for Payer: Monida Montana Health Co-op |
$33.25
|
| Rate for Payer: Monida PacificSource |
$33.25
|
|
|
CAST PADDING 4''
|
Facility
|
IP
|
$35.00
|
|
|
Service Code
|
HCPCS A4590
|
| Hospital Charge Code |
80030072
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$24.50 |
| Max. Negotiated Rate |
$35.00 |
| Rate for Payer: Aetna Commercial |
$33.25
|
| Rate for Payer: Aetna Medicare |
$31.50
|
| Rate for Payer: BCBS MT CHIP |
$31.50
|
| Rate for Payer: BCBS MT Closed Plan Network |
$33.25
|
| Rate for Payer: BCBS MT HealthLink |
$31.50
|
| Rate for Payer: BCBS MT Medicare |
$31.50
|
| Rate for Payer: BCBS MT POS |
$33.25
|
| Rate for Payer: BCBS MT Traditional |
$35.00
|
| Rate for Payer: Cash Price |
$31.50
|
| Rate for Payer: Cigna Commercial |
$33.25
|
| Rate for Payer: Cigna Medicare |
$31.50
|
| Rate for Payer: Medicaid All Medicaid |
$32.20
|
| Rate for Payer: Medicare All Medicare |
$24.50
|
| Rate for Payer: Monida Allegiance |
$33.25
|
| Rate for Payer: Monida First Choice Health |
$33.95
|
| Rate for Payer: Monida Montana Health Co-op |
$33.25
|
| Rate for Payer: Monida PacificSource |
$33.25
|
|
|
CAST SHOE L FEMALE
|
Facility
|
IP
|
$25.00
|
|
| Hospital Charge Code |
2893222
|
|
Hospital Revenue Code
|
290
|
| 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
|
|
|
CAST SHOE L FEMALE
|
Facility
|
OP
|
$25.00
|
|
| Hospital Charge Code |
2893222
|
|
Hospital Revenue Code
|
290
|
| 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
|
|
|
CAST SHOE L MALE
|
Facility
|
IP
|
$23.00
|
|
| Hospital Charge Code |
2893226
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$16.10 |
| Max. Negotiated Rate |
$23.00 |
| Rate for Payer: Aetna Commercial |
$21.85
|
| Rate for Payer: Aetna Medicare |
$20.70
|
| Rate for Payer: BCBS MT CHIP |
$20.70
|
| Rate for Payer: BCBS MT Closed Plan Network |
$21.85
|
| Rate for Payer: BCBS MT HealthLink |
$20.70
|
| Rate for Payer: BCBS MT Medicare |
$20.70
|
| Rate for Payer: BCBS MT POS |
$21.85
|
| Rate for Payer: BCBS MT Traditional |
$23.00
|
| Rate for Payer: Cash Price |
$20.70
|
| Rate for Payer: Cigna Commercial |
$21.85
|
| Rate for Payer: Cigna Medicare |
$20.70
|
| Rate for Payer: Medicaid All Medicaid |
$21.16
|
| Rate for Payer: Medicare All Medicare |
$16.10
|
| Rate for Payer: Monida Allegiance |
$21.85
|
| Rate for Payer: Monida First Choice Health |
$22.31
|
| Rate for Payer: Monida Montana Health Co-op |
$21.85
|
| Rate for Payer: Monida PacificSource |
$21.85
|
|
|
CAST SHOE L MALE
|
Facility
|
OP
|
$23.00
|
|
| Hospital Charge Code |
2893226
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$16.10 |
| Max. Negotiated Rate |
$23.00 |
| Rate for Payer: Aetna Commercial |
$21.85
|
| Rate for Payer: Aetna Medicare |
$20.70
|
| Rate for Payer: BCBS MT CHIP |
$20.70
|
| Rate for Payer: BCBS MT Closed Plan Network |
$21.85
|
| Rate for Payer: BCBS MT HealthLink |
$20.70
|
| Rate for Payer: BCBS MT Medicare |
$20.70
|
| Rate for Payer: BCBS MT POS |
$21.85
|
| Rate for Payer: BCBS MT Traditional |
$23.00
|
| Rate for Payer: Cash Price |
$20.70
|
| Rate for Payer: Cigna Commercial |
$21.85
|
| Rate for Payer: Cigna Medicare |
$20.70
|
| Rate for Payer: Medicaid All Medicaid |
$21.16
|
| Rate for Payer: Medicare All Medicare |
$16.10
|
| Rate for Payer: Monida Allegiance |
$21.85
|
| Rate for Payer: Monida First Choice Health |
$22.31
|
| Rate for Payer: Monida Montana Health Co-op |
$21.85
|
| Rate for Payer: Monida PacificSource |
$21.85
|
|
|
CAST SHOE M FEMALE
|
Facility
|
OP
|
$25.00
|
|
| Hospital Charge Code |
2893221
|
|
Hospital Revenue Code
|
290
|
| 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
|
|
|
CAST SHOE M FEMALE
|
Facility
|
IP
|
$25.00
|
|
| Hospital Charge Code |
2893221
|
|
Hospital Revenue Code
|
290
|
| 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
|
|
|
CAST SHOE M MALE
|
Facility
|
OP
|
$23.00
|
|
| Hospital Charge Code |
2893225
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$16.10 |
| Max. Negotiated Rate |
$23.00 |
| Rate for Payer: Aetna Commercial |
$21.85
|
| Rate for Payer: Aetna Medicare |
$20.70
|
| Rate for Payer: BCBS MT CHIP |
$20.70
|
| Rate for Payer: BCBS MT Closed Plan Network |
$21.85
|
| Rate for Payer: BCBS MT HealthLink |
$20.70
|
| Rate for Payer: BCBS MT Medicare |
$20.70
|
| Rate for Payer: BCBS MT POS |
$21.85
|
| Rate for Payer: BCBS MT Traditional |
$23.00
|
| Rate for Payer: Cash Price |
$20.70
|
| Rate for Payer: Cigna Commercial |
$21.85
|
| Rate for Payer: Cigna Medicare |
$20.70
|
| Rate for Payer: Medicaid All Medicaid |
$21.16
|
| Rate for Payer: Medicare All Medicare |
$16.10
|
| Rate for Payer: Monida Allegiance |
$21.85
|
| Rate for Payer: Monida First Choice Health |
$22.31
|
| Rate for Payer: Monida Montana Health Co-op |
$21.85
|
| Rate for Payer: Monida PacificSource |
$21.85
|
|
|
CAST SHOE M MALE
|
Facility
|
IP
|
$23.00
|
|
| Hospital Charge Code |
2893225
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$16.10 |
| Max. Negotiated Rate |
$23.00 |
| Rate for Payer: Aetna Commercial |
$21.85
|
| Rate for Payer: Aetna Medicare |
$20.70
|
| Rate for Payer: BCBS MT CHIP |
$20.70
|
| Rate for Payer: BCBS MT Closed Plan Network |
$21.85
|
| Rate for Payer: BCBS MT HealthLink |
$20.70
|
| Rate for Payer: BCBS MT Medicare |
$20.70
|
| Rate for Payer: BCBS MT POS |
$21.85
|
| Rate for Payer: BCBS MT Traditional |
$23.00
|
| Rate for Payer: Cash Price |
$20.70
|
| Rate for Payer: Cigna Commercial |
$21.85
|
| Rate for Payer: Cigna Medicare |
$20.70
|
| Rate for Payer: Medicaid All Medicaid |
$21.16
|
| Rate for Payer: Medicare All Medicare |
$16.10
|
| Rate for Payer: Monida Allegiance |
$21.85
|
| Rate for Payer: Monida First Choice Health |
$22.31
|
| Rate for Payer: Monida Montana Health Co-op |
$21.85
|
| Rate for Payer: Monida PacificSource |
$21.85
|
|
|
CAST SHOE S FEMALE
|
Facility
|
OP
|
$25.00
|
|
| Hospital Charge Code |
2893220
|
|
Hospital Revenue Code
|
290
|
| 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
|
|
|
CAST SHOE S FEMALE
|
Facility
|
IP
|
$25.00
|
|
| Hospital Charge Code |
2893220
|
|
Hospital Revenue Code
|
290
|
| 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
|
|
|
CAST SHOE S MALE
|
Facility
|
IP
|
$22.00
|
|
| Hospital Charge Code |
2893224
|
|
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
|
|
|
CAST SHOE S MALE
|
Facility
|
OP
|
$22.00
|
|
| Hospital Charge Code |
2893224
|
|
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
|
|
|
CAST SHOE XL MALE
|
Facility
|
OP
|
$23.00
|
|
| Hospital Charge Code |
2893227
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$16.10 |
| Max. Negotiated Rate |
$23.00 |
| Rate for Payer: Aetna Commercial |
$21.85
|
| Rate for Payer: Aetna Medicare |
$20.70
|
| Rate for Payer: BCBS MT CHIP |
$20.70
|
| Rate for Payer: BCBS MT Closed Plan Network |
$21.85
|
| Rate for Payer: BCBS MT HealthLink |
$20.70
|
| Rate for Payer: BCBS MT Medicare |
$20.70
|
| Rate for Payer: BCBS MT POS |
$21.85
|
| Rate for Payer: BCBS MT Traditional |
$23.00
|
| Rate for Payer: Cash Price |
$20.70
|
| Rate for Payer: Cigna Commercial |
$21.85
|
| Rate for Payer: Cigna Medicare |
$20.70
|
| Rate for Payer: Medicaid All Medicaid |
$21.16
|
| Rate for Payer: Medicare All Medicare |
$16.10
|
| Rate for Payer: Monida Allegiance |
$21.85
|
| Rate for Payer: Monida First Choice Health |
$22.31
|
| Rate for Payer: Monida Montana Health Co-op |
$21.85
|
| Rate for Payer: Monida PacificSource |
$21.85
|
|
|
CAST SHOE XL MALE
|
Facility
|
IP
|
$23.00
|
|
| Hospital Charge Code |
2893227
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$16.10 |
| Max. Negotiated Rate |
$23.00 |
| Rate for Payer: Aetna Commercial |
$21.85
|
| Rate for Payer: Aetna Medicare |
$20.70
|
| Rate for Payer: BCBS MT CHIP |
$20.70
|
| Rate for Payer: BCBS MT Closed Plan Network |
$21.85
|
| Rate for Payer: BCBS MT HealthLink |
$20.70
|
| Rate for Payer: BCBS MT Medicare |
$20.70
|
| Rate for Payer: BCBS MT POS |
$21.85
|
| Rate for Payer: BCBS MT Traditional |
$23.00
|
| Rate for Payer: Cash Price |
$20.70
|
| Rate for Payer: Cigna Commercial |
$21.85
|
| Rate for Payer: Cigna Medicare |
$20.70
|
| Rate for Payer: Medicaid All Medicaid |
$21.16
|
| Rate for Payer: Medicare All Medicare |
$16.10
|
| Rate for Payer: Monida Allegiance |
$21.85
|
| Rate for Payer: Monida First Choice Health |
$22.31
|
| Rate for Payer: Monida Montana Health Co-op |
$21.85
|
| Rate for Payer: Monida PacificSource |
$21.85
|
|
|
CAST SHOE XS FEMALE
|
Facility
|
IP
|
$30.00
|
|
|
Service Code
|
HCPCS A4590
|
| Hospital Charge Code |
2830066
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$21.00 |
| Max. Negotiated Rate |
$30.00 |
| Rate for Payer: Aetna Commercial |
$28.50
|
| Rate for Payer: Aetna Medicare |
$27.00
|
| Rate for Payer: BCBS MT CHIP |
$27.00
|
| Rate for Payer: BCBS MT Closed Plan Network |
$28.50
|
| Rate for Payer: BCBS MT HealthLink |
$27.00
|
| Rate for Payer: BCBS MT Medicare |
$27.00
|
| Rate for Payer: BCBS MT POS |
$28.50
|
| Rate for Payer: BCBS MT Traditional |
$30.00
|
| Rate for Payer: Cash Price |
$27.00
|
| Rate for Payer: Cigna Commercial |
$28.50
|
| Rate for Payer: Cigna Medicare |
$27.00
|
| Rate for Payer: Medicaid All Medicaid |
$27.60
|
| Rate for Payer: Medicare All Medicare |
$21.00
|
| Rate for Payer: Monida Allegiance |
$28.50
|
| Rate for Payer: Monida First Choice Health |
$29.10
|
| Rate for Payer: Monida Montana Health Co-op |
$28.50
|
| Rate for Payer: Monida PacificSource |
$28.50
|
|
|
CAST SHOE XS FEMALE
|
Facility
|
OP
|
$30.00
|
|
|
Service Code
|
HCPCS A4590
|
| Hospital Charge Code |
2830066
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$21.00 |
| Max. Negotiated Rate |
$30.00 |
| Rate for Payer: Aetna Commercial |
$28.50
|
| Rate for Payer: Aetna Medicare |
$27.00
|
| Rate for Payer: BCBS MT CHIP |
$27.00
|
| Rate for Payer: BCBS MT Closed Plan Network |
$28.50
|
| Rate for Payer: BCBS MT HealthLink |
$27.00
|
| Rate for Payer: BCBS MT Medicare |
$27.00
|
| Rate for Payer: BCBS MT POS |
$28.50
|
| Rate for Payer: BCBS MT Traditional |
$30.00
|
| Rate for Payer: Cash Price |
$27.00
|
| Rate for Payer: Cigna Commercial |
$28.50
|
| Rate for Payer: Cigna Medicare |
$27.00
|
| Rate for Payer: Medicaid All Medicaid |
$27.60
|
| Rate for Payer: Medicare All Medicare |
$21.00
|
| Rate for Payer: Monida Allegiance |
$28.50
|
| Rate for Payer: Monida First Choice Health |
$29.10
|
| Rate for Payer: Monida Montana Health Co-op |
$28.50
|
| Rate for Payer: Monida PacificSource |
$28.50
|
|
|
CAST SHOE XS MALE
|
Facility
|
IP
|
$23.00
|
|
| Hospital Charge Code |
2893223
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$16.10 |
| Max. Negotiated Rate |
$23.00 |
| Rate for Payer: Aetna Commercial |
$21.85
|
| Rate for Payer: Aetna Medicare |
$20.70
|
| Rate for Payer: BCBS MT CHIP |
$20.70
|
| Rate for Payer: BCBS MT Closed Plan Network |
$21.85
|
| Rate for Payer: BCBS MT HealthLink |
$20.70
|
| Rate for Payer: BCBS MT Medicare |
$20.70
|
| Rate for Payer: BCBS MT POS |
$21.85
|
| Rate for Payer: BCBS MT Traditional |
$23.00
|
| Rate for Payer: Cash Price |
$20.70
|
| Rate for Payer: Cigna Commercial |
$21.85
|
| Rate for Payer: Cigna Medicare |
$20.70
|
| Rate for Payer: Medicaid All Medicaid |
$21.16
|
| Rate for Payer: Medicare All Medicare |
$16.10
|
| Rate for Payer: Monida Allegiance |
$21.85
|
| Rate for Payer: Monida First Choice Health |
$22.31
|
| Rate for Payer: Monida Montana Health Co-op |
$21.85
|
| Rate for Payer: Monida PacificSource |
$21.85
|
|
|
CAST SHOE XS MALE
|
Facility
|
OP
|
$23.00
|
|
| Hospital Charge Code |
2893223
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$16.10 |
| Max. Negotiated Rate |
$23.00 |
| Rate for Payer: Aetna Commercial |
$21.85
|
| Rate for Payer: Aetna Medicare |
$20.70
|
| Rate for Payer: BCBS MT CHIP |
$20.70
|
| Rate for Payer: BCBS MT Closed Plan Network |
$21.85
|
| Rate for Payer: BCBS MT HealthLink |
$20.70
|
| Rate for Payer: BCBS MT Medicare |
$20.70
|
| Rate for Payer: BCBS MT POS |
$21.85
|
| Rate for Payer: BCBS MT Traditional |
$23.00
|
| Rate for Payer: Cash Price |
$20.70
|
| Rate for Payer: Cigna Commercial |
$21.85
|
| Rate for Payer: Cigna Medicare |
$20.70
|
| Rate for Payer: Medicaid All Medicaid |
$21.16
|
| Rate for Payer: Medicare All Medicare |
$16.10
|
| Rate for Payer: Monida Allegiance |
$21.85
|
| Rate for Payer: Monida First Choice Health |
$22.31
|
| Rate for Payer: Monida Montana Health Co-op |
$21.85
|
| Rate for Payer: Monida PacificSource |
$21.85
|
|
|
CAST SHORT LEG
|
Facility
|
IP
|
$345.00
|
|
| Hospital Charge Code |
1050909
|
|
Hospital Revenue Code
|
230
|
| Min. Negotiated Rate |
$241.50 |
| Max. Negotiated Rate |
$345.00 |
| Rate for Payer: Aetna Commercial |
$327.75
|
| Rate for Payer: Aetna Medicare |
$310.50
|
| Rate for Payer: BCBS MT CHIP |
$310.50
|
| Rate for Payer: BCBS MT Closed Plan Network |
$327.75
|
| Rate for Payer: BCBS MT HealthLink |
$310.50
|
| Rate for Payer: BCBS MT Medicare |
$310.50
|
| Rate for Payer: BCBS MT POS |
$327.75
|
| Rate for Payer: BCBS MT Traditional |
$345.00
|
| Rate for Payer: Cash Price |
$310.50
|
| Rate for Payer: Cigna Commercial |
$327.75
|
| Rate for Payer: Cigna Medicare |
$310.50
|
| Rate for Payer: Medicaid All Medicaid |
$317.40
|
| Rate for Payer: Medicare All Medicare |
$241.50
|
| Rate for Payer: Monida Allegiance |
$327.75
|
| Rate for Payer: Monida First Choice Health |
$334.65
|
| Rate for Payer: Monida Montana Health Co-op |
$327.75
|
| Rate for Payer: Monida PacificSource |
$327.75
|
|
|
CAST SHORT LEG
|
Facility
|
OP
|
$345.00
|
|
| Hospital Charge Code |
1050909
|
|
Hospital Revenue Code
|
230
|
| Min. Negotiated Rate |
$241.50 |
| Max. Negotiated Rate |
$345.00 |
| Rate for Payer: Aetna Commercial |
$327.75
|
| Rate for Payer: Aetna Medicare |
$310.50
|
| Rate for Payer: BCBS MT CHIP |
$310.50
|
| Rate for Payer: BCBS MT Closed Plan Network |
$327.75
|
| Rate for Payer: BCBS MT HealthLink |
$310.50
|
| Rate for Payer: BCBS MT Medicare |
$310.50
|
| Rate for Payer: BCBS MT POS |
$327.75
|
| Rate for Payer: BCBS MT Traditional |
$345.00
|
| Rate for Payer: Cash Price |
$310.50
|
| Rate for Payer: Cigna Commercial |
$327.75
|
| Rate for Payer: Cigna Medicare |
$310.50
|
| Rate for Payer: Medicaid All Medicaid |
$317.40
|
| Rate for Payer: Medicare All Medicare |
$241.50
|
| Rate for Payer: Monida Allegiance |
$327.75
|
| Rate for Payer: Monida First Choice Health |
$334.65
|
| Rate for Payer: Monida Montana Health Co-op |
$327.75
|
| Rate for Payer: Monida PacificSource |
$327.75
|
|
|
CATHETER 12FR 5CC
|
Facility
|
IP
|
$20.00
|
|
| Hospital Charge Code |
80030073
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$14.00 |
| Max. Negotiated Rate |
$20.00 |
| Rate for Payer: Aetna Commercial |
$19.00
|
| Rate for Payer: Aetna Medicare |
$18.00
|
| Rate for Payer: BCBS MT CHIP |
$18.00
|
| Rate for Payer: BCBS MT Closed Plan Network |
$19.00
|
| Rate for Payer: BCBS MT HealthLink |
$18.00
|
| Rate for Payer: BCBS MT Medicare |
$18.00
|
| Rate for Payer: BCBS MT POS |
$19.00
|
| Rate for Payer: BCBS MT Traditional |
$20.00
|
| Rate for Payer: Cash Price |
$18.00
|
| Rate for Payer: Cigna Commercial |
$19.00
|
| Rate for Payer: Cigna Medicare |
$18.00
|
| Rate for Payer: Medicaid All Medicaid |
$18.40
|
| Rate for Payer: Medicare All Medicare |
$14.00
|
| Rate for Payer: Monida Allegiance |
$19.00
|
| Rate for Payer: Monida First Choice Health |
$19.40
|
| Rate for Payer: Monida Montana Health Co-op |
$19.00
|
| Rate for Payer: Monida PacificSource |
$19.00
|
|
|
CATHETER 12FR 5CC
|
Facility
|
OP
|
$20.00
|
|
| Hospital Charge Code |
80030073
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$14.00 |
| Max. Negotiated Rate |
$20.00 |
| Rate for Payer: Aetna Commercial |
$19.00
|
| Rate for Payer: Aetna Medicare |
$18.00
|
| Rate for Payer: BCBS MT CHIP |
$18.00
|
| Rate for Payer: BCBS MT Closed Plan Network |
$19.00
|
| Rate for Payer: BCBS MT HealthLink |
$18.00
|
| Rate for Payer: BCBS MT Medicare |
$18.00
|
| Rate for Payer: BCBS MT POS |
$19.00
|
| Rate for Payer: BCBS MT Traditional |
$20.00
|
| Rate for Payer: Cash Price |
$18.00
|
| Rate for Payer: Cigna Commercial |
$19.00
|
| Rate for Payer: Cigna Medicare |
$18.00
|
| Rate for Payer: Medicaid All Medicaid |
$18.40
|
| Rate for Payer: Medicare All Medicare |
$14.00
|
| Rate for Payer: Monida Allegiance |
$19.00
|
| Rate for Payer: Monida First Choice Health |
$19.40
|
| Rate for Payer: Monida Montana Health Co-op |
$19.00
|
| Rate for Payer: Monida PacificSource |
$19.00
|
|
