|
CARPEL TUNNEL SUPP LEFT XLG
|
Facility
|
OP
|
$29.00
|
|
| Hospital Charge Code |
2893218
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$20.30 |
| Max. Negotiated Rate |
$29.00 |
| Rate for Payer: Aetna Commercial |
$27.55
|
| Rate for Payer: Aetna Medicare |
$26.10
|
| Rate for Payer: BCBS MT CHIP |
$26.10
|
| Rate for Payer: BCBS MT Closed Plan Network |
$27.55
|
| Rate for Payer: BCBS MT HealthLink |
$26.10
|
| Rate for Payer: BCBS MT Medicare |
$26.10
|
| Rate for Payer: BCBS MT POS |
$27.55
|
| Rate for Payer: BCBS MT Traditional |
$29.00
|
| Rate for Payer: Cash Price |
$26.10
|
| Rate for Payer: Cigna Commercial |
$27.55
|
| Rate for Payer: Cigna Medicare |
$26.10
|
| Rate for Payer: Medicaid All Medicaid |
$26.68
|
| Rate for Payer: Medicare All Medicare |
$20.30
|
| Rate for Payer: Monida Allegiance |
$27.55
|
| Rate for Payer: Monida First Choice Health |
$28.13
|
| Rate for Payer: Monida Montana Health Co-op |
$27.55
|
| Rate for Payer: Monida PacificSource |
$27.55
|
|
|
CARPEL TUNNEL SUPP R LG
|
Facility
|
OP
|
$29.00
|
|
| Hospital Charge Code |
2893215
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$20.30 |
| Max. Negotiated Rate |
$29.00 |
| Rate for Payer: Aetna Commercial |
$27.55
|
| Rate for Payer: Aetna Medicare |
$26.10
|
| Rate for Payer: BCBS MT CHIP |
$26.10
|
| Rate for Payer: BCBS MT Closed Plan Network |
$27.55
|
| Rate for Payer: BCBS MT HealthLink |
$26.10
|
| Rate for Payer: BCBS MT Medicare |
$26.10
|
| Rate for Payer: BCBS MT POS |
$27.55
|
| Rate for Payer: BCBS MT Traditional |
$29.00
|
| Rate for Payer: Cash Price |
$26.10
|
| Rate for Payer: Cigna Commercial |
$27.55
|
| Rate for Payer: Cigna Medicare |
$26.10
|
| Rate for Payer: Medicaid All Medicaid |
$26.68
|
| Rate for Payer: Medicare All Medicare |
$20.30
|
| Rate for Payer: Monida Allegiance |
$27.55
|
| Rate for Payer: Monida First Choice Health |
$28.13
|
| Rate for Payer: Monida Montana Health Co-op |
$27.55
|
| Rate for Payer: Monida PacificSource |
$27.55
|
|
|
CARPEL TUNNEL SUPP R LG
|
Facility
|
IP
|
$29.00
|
|
| Hospital Charge Code |
2893215
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$20.30 |
| Max. Negotiated Rate |
$29.00 |
| Rate for Payer: Aetna Commercial |
$27.55
|
| Rate for Payer: Aetna Medicare |
$26.10
|
| Rate for Payer: BCBS MT CHIP |
$26.10
|
| Rate for Payer: BCBS MT Closed Plan Network |
$27.55
|
| Rate for Payer: BCBS MT HealthLink |
$26.10
|
| Rate for Payer: BCBS MT Medicare |
$26.10
|
| Rate for Payer: BCBS MT POS |
$27.55
|
| Rate for Payer: BCBS MT Traditional |
$29.00
|
| Rate for Payer: Cash Price |
$26.10
|
| Rate for Payer: Cigna Commercial |
$27.55
|
| Rate for Payer: Cigna Medicare |
$26.10
|
| Rate for Payer: Medicaid All Medicaid |
$26.68
|
| Rate for Payer: Medicare All Medicare |
$20.30
|
| Rate for Payer: Monida Allegiance |
$27.55
|
| Rate for Payer: Monida First Choice Health |
$28.13
|
| Rate for Payer: Monida Montana Health Co-op |
$27.55
|
| Rate for Payer: Monida PacificSource |
$27.55
|
|
|
CARPEL TUNNEL SUPP R MED
|
Facility
|
IP
|
$33.00
|
|
| Hospital Charge Code |
2862608
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$23.10 |
| Max. Negotiated Rate |
$33.00 |
| Rate for Payer: Aetna Commercial |
$31.35
|
| Rate for Payer: Aetna Medicare |
$29.70
|
| Rate for Payer: BCBS MT CHIP |
$29.70
|
| Rate for Payer: BCBS MT Closed Plan Network |
$31.35
|
| Rate for Payer: BCBS MT HealthLink |
$29.70
|
| Rate for Payer: BCBS MT Medicare |
$29.70
|
| Rate for Payer: BCBS MT POS |
$31.35
|
| Rate for Payer: BCBS MT Traditional |
$33.00
|
| Rate for Payer: Cash Price |
$29.70
|
| Rate for Payer: Cigna Commercial |
$31.35
|
| Rate for Payer: Cigna Medicare |
$29.70
|
| Rate for Payer: Medicaid All Medicaid |
$30.36
|
| Rate for Payer: Medicare All Medicare |
$23.10
|
| Rate for Payer: Monida Allegiance |
$31.35
|
| Rate for Payer: Monida First Choice Health |
$32.01
|
| Rate for Payer: Monida Montana Health Co-op |
$31.35
|
| Rate for Payer: Monida PacificSource |
$31.35
|
|
|
CARPEL TUNNEL SUPP R MED
|
Facility
|
OP
|
$33.00
|
|
| Hospital Charge Code |
2862608
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$23.10 |
| Max. Negotiated Rate |
$33.00 |
| Rate for Payer: Aetna Commercial |
$31.35
|
| Rate for Payer: Aetna Medicare |
$29.70
|
| Rate for Payer: BCBS MT CHIP |
$29.70
|
| Rate for Payer: BCBS MT Closed Plan Network |
$31.35
|
| Rate for Payer: BCBS MT HealthLink |
$29.70
|
| Rate for Payer: BCBS MT Medicare |
$29.70
|
| Rate for Payer: BCBS MT POS |
$31.35
|
| Rate for Payer: BCBS MT Traditional |
$33.00
|
| Rate for Payer: Cash Price |
$29.70
|
| Rate for Payer: Cigna Commercial |
$31.35
|
| Rate for Payer: Cigna Medicare |
$29.70
|
| Rate for Payer: Medicaid All Medicaid |
$30.36
|
| Rate for Payer: Medicare All Medicare |
$23.10
|
| Rate for Payer: Monida Allegiance |
$31.35
|
| Rate for Payer: Monida First Choice Health |
$32.01
|
| Rate for Payer: Monida Montana Health Co-op |
$31.35
|
| Rate for Payer: Monida PacificSource |
$31.35
|
|
|
CARPEL TUNNEL SUPP UNIV LG
|
Facility
|
IP
|
$30.00
|
|
| Hospital Charge Code |
2893219
|
|
Hospital Revenue Code
|
290
|
| 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
|
|
|
CARPEL TUNNEL SUPP UNIV LG
|
Facility
|
OP
|
$30.00
|
|
| Hospital Charge Code |
2893219
|
|
Hospital Revenue Code
|
290
|
| 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
|
|
|
CARTRIDGE, TEST CHEM8+ I-STAT (25/BX)
|
Facility
|
OP
|
$214.00
|
|
|
Service Code
|
HCPCS 80047
|
| Hospital Charge Code |
4080047
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$149.80 |
| Max. Negotiated Rate |
$214.00 |
| Rate for Payer: Aetna Commercial |
$203.30
|
| Rate for Payer: Aetna Medicare |
$192.60
|
| Rate for Payer: BCBS MT CHIP |
$192.60
|
| Rate for Payer: BCBS MT Closed Plan Network |
$203.30
|
| Rate for Payer: BCBS MT HealthLink |
$192.60
|
| Rate for Payer: BCBS MT Medicare |
$192.60
|
| Rate for Payer: BCBS MT POS |
$203.30
|
| Rate for Payer: BCBS MT Traditional |
$214.00
|
| Rate for Payer: Cash Price |
$192.60
|
| Rate for Payer: Cigna Commercial |
$203.30
|
| Rate for Payer: Cigna Medicare |
$192.60
|
| Rate for Payer: Medicaid All Medicaid |
$196.88
|
| Rate for Payer: Medicare All Medicare |
$149.80
|
| Rate for Payer: Monida Allegiance |
$203.30
|
| Rate for Payer: Monida First Choice Health |
$207.58
|
| Rate for Payer: Monida Montana Health Co-op |
$203.30
|
| Rate for Payer: Monida PacificSource |
$203.30
|
|
|
CARTRIDGE, TEST CHEM8+ I-STAT (25/BX)
|
Facility
|
IP
|
$214.00
|
|
|
Service Code
|
HCPCS 80047
|
| Hospital Charge Code |
4080047
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$149.80 |
| Max. Negotiated Rate |
$214.00 |
| Rate for Payer: Aetna Commercial |
$203.30
|
| Rate for Payer: Aetna Medicare |
$192.60
|
| Rate for Payer: BCBS MT CHIP |
$192.60
|
| Rate for Payer: BCBS MT Closed Plan Network |
$203.30
|
| Rate for Payer: BCBS MT HealthLink |
$192.60
|
| Rate for Payer: BCBS MT Medicare |
$192.60
|
| Rate for Payer: BCBS MT POS |
$203.30
|
| Rate for Payer: BCBS MT Traditional |
$214.00
|
| Rate for Payer: Cash Price |
$192.60
|
| Rate for Payer: Cigna Commercial |
$203.30
|
| Rate for Payer: Cigna Medicare |
$192.60
|
| Rate for Payer: Medicaid All Medicaid |
$196.88
|
| Rate for Payer: Medicare All Medicare |
$149.80
|
| Rate for Payer: Monida Allegiance |
$203.30
|
| Rate for Payer: Monida First Choice Health |
$207.58
|
| Rate for Payer: Monida Montana Health Co-op |
$203.30
|
| Rate for Payer: Monida PacificSource |
$203.30
|
|
|
CARVEDILOL TAB [12.5 MG] NF
|
Facility
|
IP
|
$8.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
3000070
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.60 |
| Max. Negotiated Rate |
$8.00 |
| Rate for Payer: Aetna Commercial |
$7.60
|
| Rate for Payer: Aetna Medicare |
$7.20
|
| Rate for Payer: BCBS MT CHIP |
$7.20
|
| Rate for Payer: BCBS MT Closed Plan Network |
$7.60
|
| Rate for Payer: BCBS MT HealthLink |
$7.20
|
| Rate for Payer: BCBS MT Medicare |
$7.20
|
| Rate for Payer: BCBS MT POS |
$7.60
|
| Rate for Payer: BCBS MT Traditional |
$8.00
|
| Rate for Payer: Cash Price |
$7.20
|
| Rate for Payer: Cigna Commercial |
$7.60
|
| Rate for Payer: Cigna Medicare |
$7.20
|
| Rate for Payer: Medicaid All Medicaid |
$7.36
|
| Rate for Payer: Medicare All Medicare |
$5.60
|
| Rate for Payer: Monida Allegiance |
$7.60
|
| Rate for Payer: Monida First Choice Health |
$7.76
|
| Rate for Payer: Monida Montana Health Co-op |
$7.60
|
| Rate for Payer: Monida PacificSource |
$7.60
|
|
|
CARVEDILOL TAB [12.5 MG] NF
|
Facility
|
OP
|
$8.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
3000070
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.60 |
| Max. Negotiated Rate |
$8.00 |
| Rate for Payer: Aetna Commercial |
$7.60
|
| Rate for Payer: Aetna Medicare |
$7.20
|
| Rate for Payer: BCBS MT CHIP |
$7.20
|
| Rate for Payer: BCBS MT Closed Plan Network |
$7.60
|
| Rate for Payer: BCBS MT HealthLink |
$7.20
|
| Rate for Payer: BCBS MT Medicare |
$7.20
|
| Rate for Payer: BCBS MT POS |
$7.60
|
| Rate for Payer: BCBS MT Traditional |
$8.00
|
| Rate for Payer: Cash Price |
$7.20
|
| Rate for Payer: Cigna Commercial |
$7.60
|
| Rate for Payer: Cigna Medicare |
$7.20
|
| Rate for Payer: Medicaid All Medicaid |
$7.36
|
| Rate for Payer: Medicare All Medicare |
$5.60
|
| Rate for Payer: Monida Allegiance |
$7.60
|
| Rate for Payer: Monida First Choice Health |
$7.76
|
| Rate for Payer: Monida Montana Health Co-op |
$7.60
|
| Rate for Payer: Monida PacificSource |
$7.60
|
|
|
CARVEDILOL TAB [3.125 MG] NF
|
Facility
|
OP
|
$8.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
3000071
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.60 |
| Max. Negotiated Rate |
$8.00 |
| Rate for Payer: Aetna Commercial |
$7.60
|
| Rate for Payer: Aetna Medicare |
$7.20
|
| Rate for Payer: BCBS MT CHIP |
$7.20
|
| Rate for Payer: BCBS MT Closed Plan Network |
$7.60
|
| Rate for Payer: BCBS MT HealthLink |
$7.20
|
| Rate for Payer: BCBS MT Medicare |
$7.20
|
| Rate for Payer: BCBS MT POS |
$7.60
|
| Rate for Payer: BCBS MT Traditional |
$8.00
|
| Rate for Payer: Cash Price |
$7.20
|
| Rate for Payer: Cigna Commercial |
$7.60
|
| Rate for Payer: Cigna Medicare |
$7.20
|
| Rate for Payer: Medicaid All Medicaid |
$7.36
|
| Rate for Payer: Medicare All Medicare |
$5.60
|
| Rate for Payer: Monida Allegiance |
$7.60
|
| Rate for Payer: Monida First Choice Health |
$7.76
|
| Rate for Payer: Monida Montana Health Co-op |
$7.60
|
| Rate for Payer: Monida PacificSource |
$7.60
|
|
|
CARVEDILOL TAB [3.125 MG] NF
|
Facility
|
IP
|
$8.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
3000071
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.60 |
| Max. Negotiated Rate |
$8.00 |
| Rate for Payer: Aetna Commercial |
$7.60
|
| Rate for Payer: Aetna Medicare |
$7.20
|
| Rate for Payer: BCBS MT CHIP |
$7.20
|
| Rate for Payer: BCBS MT Closed Plan Network |
$7.60
|
| Rate for Payer: BCBS MT HealthLink |
$7.20
|
| Rate for Payer: BCBS MT Medicare |
$7.20
|
| Rate for Payer: BCBS MT POS |
$7.60
|
| Rate for Payer: BCBS MT Traditional |
$8.00
|
| Rate for Payer: Cash Price |
$7.20
|
| Rate for Payer: Cigna Commercial |
$7.60
|
| Rate for Payer: Cigna Medicare |
$7.20
|
| Rate for Payer: Medicaid All Medicaid |
$7.36
|
| Rate for Payer: Medicare All Medicare |
$5.60
|
| Rate for Payer: Monida Allegiance |
$7.60
|
| Rate for Payer: Monida First Choice Health |
$7.76
|
| Rate for Payer: Monida Montana Health Co-op |
$7.60
|
| Rate for Payer: Monida PacificSource |
$7.60
|
|
|
CARVEDILOL TAB [6.25 MG]
|
Facility
|
IP
|
$8.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
3000576
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.60 |
| Max. Negotiated Rate |
$8.00 |
| Rate for Payer: Aetna Commercial |
$7.60
|
| Rate for Payer: Aetna Medicare |
$7.20
|
| Rate for Payer: BCBS MT CHIP |
$7.20
|
| Rate for Payer: BCBS MT Closed Plan Network |
$7.60
|
| Rate for Payer: BCBS MT HealthLink |
$7.20
|
| Rate for Payer: BCBS MT Medicare |
$7.20
|
| Rate for Payer: BCBS MT POS |
$7.60
|
| Rate for Payer: BCBS MT Traditional |
$8.00
|
| Rate for Payer: Cash Price |
$7.20
|
| Rate for Payer: Cigna Commercial |
$7.60
|
| Rate for Payer: Cigna Medicare |
$7.20
|
| Rate for Payer: Medicaid All Medicaid |
$7.36
|
| Rate for Payer: Medicare All Medicare |
$5.60
|
| Rate for Payer: Monida Allegiance |
$7.60
|
| Rate for Payer: Monida First Choice Health |
$7.76
|
| Rate for Payer: Monida Montana Health Co-op |
$7.60
|
| Rate for Payer: Monida PacificSource |
$7.60
|
|
|
CARVEDILOL TAB [6.25 MG]
|
Facility
|
OP
|
$8.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
3000576
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.60 |
| Max. Negotiated Rate |
$8.00 |
| Rate for Payer: Aetna Commercial |
$7.60
|
| Rate for Payer: Aetna Medicare |
$7.20
|
| Rate for Payer: BCBS MT CHIP |
$7.20
|
| Rate for Payer: BCBS MT Closed Plan Network |
$7.60
|
| Rate for Payer: BCBS MT HealthLink |
$7.20
|
| Rate for Payer: BCBS MT Medicare |
$7.20
|
| Rate for Payer: BCBS MT POS |
$7.60
|
| Rate for Payer: BCBS MT Traditional |
$8.00
|
| Rate for Payer: Cash Price |
$7.20
|
| Rate for Payer: Cigna Commercial |
$7.60
|
| Rate for Payer: Cigna Medicare |
$7.20
|
| Rate for Payer: Medicaid All Medicaid |
$7.36
|
| Rate for Payer: Medicare All Medicare |
$5.60
|
| Rate for Payer: Monida Allegiance |
$7.60
|
| Rate for Payer: Monida First Choice Health |
$7.76
|
| Rate for Payer: Monida Montana Health Co-op |
$7.60
|
| Rate for Payer: Monida PacificSource |
$7.60
|
|
|
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 3''
|
Facility
|
OP
|
$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
|
$27.00
|
|
| Hospital Charge Code |
2893222
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$18.90 |
| Max. Negotiated Rate |
$27.00 |
| Rate for Payer: Aetna Commercial |
$25.65
|
| Rate for Payer: Aetna Medicare |
$24.30
|
| Rate for Payer: BCBS MT CHIP |
$24.30
|
| Rate for Payer: BCBS MT Closed Plan Network |
$25.65
|
| Rate for Payer: BCBS MT HealthLink |
$24.30
|
| Rate for Payer: BCBS MT Medicare |
$24.30
|
| Rate for Payer: BCBS MT POS |
$25.65
|
| Rate for Payer: BCBS MT Traditional |
$27.00
|
| Rate for Payer: Cash Price |
$24.30
|
| Rate for Payer: Cigna Commercial |
$25.65
|
| Rate for Payer: Cigna Medicare |
$24.30
|
| Rate for Payer: Medicaid All Medicaid |
$24.84
|
| Rate for Payer: Medicare All Medicare |
$18.90
|
| Rate for Payer: Monida Allegiance |
$25.65
|
| Rate for Payer: Monida First Choice Health |
$26.19
|
| Rate for Payer: Monida Montana Health Co-op |
$25.65
|
| Rate for Payer: Monida PacificSource |
$25.65
|
|
|
CAST SHOE L FEMALE
|
Facility
|
OP
|
$27.00
|
|
| Hospital Charge Code |
2893222
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$18.90 |
| Max. Negotiated Rate |
$27.00 |
| Rate for Payer: Aetna Commercial |
$25.65
|
| Rate for Payer: Aetna Medicare |
$24.30
|
| Rate for Payer: BCBS MT CHIP |
$24.30
|
| Rate for Payer: BCBS MT Closed Plan Network |
$25.65
|
| Rate for Payer: BCBS MT HealthLink |
$24.30
|
| Rate for Payer: BCBS MT Medicare |
$24.30
|
| Rate for Payer: BCBS MT POS |
$25.65
|
| Rate for Payer: BCBS MT Traditional |
$27.00
|
| Rate for Payer: Cash Price |
$24.30
|
| Rate for Payer: Cigna Commercial |
$25.65
|
| Rate for Payer: Cigna Medicare |
$24.30
|
| Rate for Payer: Medicaid All Medicaid |
$24.84
|
| Rate for Payer: Medicare All Medicare |
$18.90
|
| Rate for Payer: Monida Allegiance |
$25.65
|
| Rate for Payer: Monida First Choice Health |
$26.19
|
| Rate for Payer: Monida Montana Health Co-op |
$25.65
|
| Rate for Payer: Monida PacificSource |
$25.65
|
|
|
CAST SHOE L MALE
|
Facility
|
IP
|
$24.00
|
|
| Hospital Charge Code |
2893226
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$16.80 |
| Max. Negotiated Rate |
$24.00 |
| Rate for Payer: Aetna Commercial |
$22.80
|
| Rate for Payer: Aetna Medicare |
$21.60
|
| Rate for Payer: BCBS MT CHIP |
$21.60
|
| Rate for Payer: BCBS MT Closed Plan Network |
$22.80
|
| Rate for Payer: BCBS MT HealthLink |
$21.60
|
| Rate for Payer: BCBS MT Medicare |
$21.60
|
| Rate for Payer: BCBS MT POS |
$22.80
|
| Rate for Payer: BCBS MT Traditional |
$24.00
|
| Rate for Payer: Cash Price |
$21.60
|
| Rate for Payer: Cigna Commercial |
$22.80
|
| Rate for Payer: Cigna Medicare |
$21.60
|
| Rate for Payer: Medicaid All Medicaid |
$22.08
|
| Rate for Payer: Medicare All Medicare |
$16.80
|
| Rate for Payer: Monida Allegiance |
$22.80
|
| Rate for Payer: Monida First Choice Health |
$23.28
|
| Rate for Payer: Monida Montana Health Co-op |
$22.80
|
| Rate for Payer: Monida PacificSource |
$22.80
|
|
|
CAST SHOE L MALE
|
Facility
|
OP
|
$24.00
|
|
| Hospital Charge Code |
2893226
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$16.80 |
| Max. Negotiated Rate |
$24.00 |
| Rate for Payer: Aetna Commercial |
$22.80
|
| Rate for Payer: Aetna Medicare |
$21.60
|
| Rate for Payer: BCBS MT CHIP |
$21.60
|
| Rate for Payer: BCBS MT Closed Plan Network |
$22.80
|
| Rate for Payer: BCBS MT HealthLink |
$21.60
|
| Rate for Payer: BCBS MT Medicare |
$21.60
|
| Rate for Payer: BCBS MT POS |
$22.80
|
| Rate for Payer: BCBS MT Traditional |
$24.00
|
| Rate for Payer: Cash Price |
$21.60
|
| Rate for Payer: Cigna Commercial |
$22.80
|
| Rate for Payer: Cigna Medicare |
$21.60
|
| Rate for Payer: Medicaid All Medicaid |
$22.08
|
| Rate for Payer: Medicare All Medicare |
$16.80
|
| Rate for Payer: Monida Allegiance |
$22.80
|
| Rate for Payer: Monida First Choice Health |
$23.28
|
| Rate for Payer: Monida Montana Health Co-op |
$22.80
|
| Rate for Payer: Monida PacificSource |
$22.80
|
|
|
CAST SHOE M FEMALE
|
Facility
|
OP
|
$27.00
|
|
| Hospital Charge Code |
2893221
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$18.90 |
| Max. Negotiated Rate |
$27.00 |
| Rate for Payer: Aetna Commercial |
$25.65
|
| Rate for Payer: Aetna Medicare |
$24.30
|
| Rate for Payer: BCBS MT CHIP |
$24.30
|
| Rate for Payer: BCBS MT Closed Plan Network |
$25.65
|
| Rate for Payer: BCBS MT HealthLink |
$24.30
|
| Rate for Payer: BCBS MT Medicare |
$24.30
|
| Rate for Payer: BCBS MT POS |
$25.65
|
| Rate for Payer: BCBS MT Traditional |
$27.00
|
| Rate for Payer: Cash Price |
$24.30
|
| Rate for Payer: Cigna Commercial |
$25.65
|
| Rate for Payer: Cigna Medicare |
$24.30
|
| Rate for Payer: Medicaid All Medicaid |
$24.84
|
| Rate for Payer: Medicare All Medicare |
$18.90
|
| Rate for Payer: Monida Allegiance |
$25.65
|
| Rate for Payer: Monida First Choice Health |
$26.19
|
| Rate for Payer: Monida Montana Health Co-op |
$25.65
|
| Rate for Payer: Monida PacificSource |
$25.65
|
|
|
CAST SHOE M FEMALE
|
Facility
|
IP
|
$27.00
|
|
| Hospital Charge Code |
2893221
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$18.90 |
| Max. Negotiated Rate |
$27.00 |
| Rate for Payer: Aetna Commercial |
$25.65
|
| Rate for Payer: Aetna Medicare |
$24.30
|
| Rate for Payer: BCBS MT CHIP |
$24.30
|
| Rate for Payer: BCBS MT Closed Plan Network |
$25.65
|
| Rate for Payer: BCBS MT HealthLink |
$24.30
|
| Rate for Payer: BCBS MT Medicare |
$24.30
|
| Rate for Payer: BCBS MT POS |
$25.65
|
| Rate for Payer: BCBS MT Traditional |
$27.00
|
| Rate for Payer: Cash Price |
$24.30
|
| Rate for Payer: Cigna Commercial |
$25.65
|
| Rate for Payer: Cigna Medicare |
$24.30
|
| Rate for Payer: Medicaid All Medicaid |
$24.84
|
| Rate for Payer: Medicare All Medicare |
$18.90
|
| Rate for Payer: Monida Allegiance |
$25.65
|
| Rate for Payer: Monida First Choice Health |
$26.19
|
| Rate for Payer: Monida Montana Health Co-op |
$25.65
|
| Rate for Payer: Monida PacificSource |
$25.65
|
|
