|
WET MOUNT, VAGINAL
|
Facility
|
OP
|
$78.00
|
|
|
Service Code
|
CPT 87210
|
| Hospital Charge Code |
4087210
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$54.60 |
| Max. Negotiated Rate |
$78.00 |
| Rate for Payer: Aetna Commercial |
$74.10
|
| Rate for Payer: Aetna Medicare |
$70.20
|
| Rate for Payer: BCBS MT CHIP |
$70.20
|
| Rate for Payer: BCBS MT Closed Plan Network |
$74.10
|
| Rate for Payer: BCBS MT HealthLink |
$70.20
|
| Rate for Payer: BCBS MT Medicare |
$70.20
|
| Rate for Payer: BCBS MT POS |
$74.10
|
| Rate for Payer: BCBS MT Traditional |
$78.00
|
| Rate for Payer: Cash Price |
$70.20
|
| Rate for Payer: Cigna Commercial |
$74.10
|
| Rate for Payer: Cigna Medicare |
$70.20
|
| Rate for Payer: Medicaid All Medicaid |
$71.76
|
| Rate for Payer: Medicare All Medicare |
$54.60
|
| Rate for Payer: Monida Allegiance |
$74.10
|
| Rate for Payer: Monida First Choice Health |
$75.66
|
| Rate for Payer: Monida Montana Health Co-op |
$74.10
|
| Rate for Payer: Monida PacificSource |
$74.10
|
|
|
WHITE BLOOD CELL COUNT, BLOOD
|
Facility
|
OP
|
$42.00
|
|
|
Service Code
|
CPT 85048
|
| Hospital Charge Code |
4085048
|
|
Hospital Revenue Code
|
305
|
| Min. Negotiated Rate |
$29.40 |
| Max. Negotiated Rate |
$42.00 |
| Rate for Payer: Aetna Commercial |
$39.90
|
| Rate for Payer: Aetna Medicare |
$37.80
|
| Rate for Payer: BCBS MT CHIP |
$37.80
|
| Rate for Payer: BCBS MT Closed Plan Network |
$39.90
|
| Rate for Payer: BCBS MT HealthLink |
$37.80
|
| Rate for Payer: BCBS MT Medicare |
$37.80
|
| Rate for Payer: BCBS MT POS |
$39.90
|
| Rate for Payer: BCBS MT Traditional |
$42.00
|
| Rate for Payer: Cash Price |
$37.80
|
| Rate for Payer: Cigna Commercial |
$39.90
|
| Rate for Payer: Cigna Medicare |
$37.80
|
| Rate for Payer: Medicaid All Medicaid |
$38.64
|
| Rate for Payer: Medicare All Medicare |
$29.40
|
| Rate for Payer: Monida Allegiance |
$39.90
|
| Rate for Payer: Monida First Choice Health |
$40.74
|
| Rate for Payer: Monida Montana Health Co-op |
$39.90
|
| Rate for Payer: Monida PacificSource |
$39.90
|
|
|
WHITE BLOOD CELL COUNT, BLOOD
|
Facility
|
IP
|
$42.00
|
|
|
Service Code
|
CPT 85048
|
| Hospital Charge Code |
4085048
|
|
Hospital Revenue Code
|
305
|
| Min. Negotiated Rate |
$29.40 |
| Max. Negotiated Rate |
$42.00 |
| Rate for Payer: Aetna Commercial |
$39.90
|
| Rate for Payer: Aetna Medicare |
$37.80
|
| Rate for Payer: BCBS MT CHIP |
$37.80
|
| Rate for Payer: BCBS MT Closed Plan Network |
$39.90
|
| Rate for Payer: BCBS MT HealthLink |
$37.80
|
| Rate for Payer: BCBS MT Medicare |
$37.80
|
| Rate for Payer: BCBS MT POS |
$39.90
|
| Rate for Payer: BCBS MT Traditional |
$42.00
|
| Rate for Payer: Cash Price |
$37.80
|
| Rate for Payer: Cigna Commercial |
$39.90
|
| Rate for Payer: Cigna Medicare |
$37.80
|
| Rate for Payer: Medicaid All Medicaid |
$38.64
|
| Rate for Payer: Medicare All Medicare |
$29.40
|
| Rate for Payer: Monida Allegiance |
$39.90
|
| Rate for Payer: Monida First Choice Health |
$40.74
|
| Rate for Payer: Monida Montana Health Co-op |
$39.90
|
| Rate for Payer: Monida PacificSource |
$39.90
|
|
|
WIPES
|
Facility
|
OP
|
$16.00
|
|
| Hospital Charge Code |
80040113
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$11.20 |
| Max. Negotiated Rate |
$16.00 |
| Rate for Payer: Aetna Commercial |
$15.20
|
| Rate for Payer: Aetna Medicare |
$14.40
|
| Rate for Payer: BCBS MT CHIP |
$14.40
|
| Rate for Payer: BCBS MT Closed Plan Network |
$15.20
|
| Rate for Payer: BCBS MT HealthLink |
$14.40
|
| Rate for Payer: BCBS MT Medicare |
$14.40
|
| Rate for Payer: BCBS MT POS |
$15.20
|
| Rate for Payer: BCBS MT Traditional |
$16.00
|
| Rate for Payer: Cash Price |
$14.40
|
| Rate for Payer: Cigna Commercial |
$15.20
|
| Rate for Payer: Cigna Medicare |
$14.40
|
| Rate for Payer: Medicaid All Medicaid |
$14.72
|
| Rate for Payer: Medicare All Medicare |
$11.20
|
| Rate for Payer: Monida Allegiance |
$15.20
|
| Rate for Payer: Monida First Choice Health |
$15.52
|
| Rate for Payer: Monida Montana Health Co-op |
$15.20
|
| Rate for Payer: Monida PacificSource |
$15.20
|
|
|
WIPES
|
Facility
|
IP
|
$16.00
|
|
| Hospital Charge Code |
80040113
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$11.20 |
| Max. Negotiated Rate |
$16.00 |
| Rate for Payer: Aetna Commercial |
$15.20
|
| Rate for Payer: Aetna Medicare |
$14.40
|
| Rate for Payer: BCBS MT CHIP |
$14.40
|
| Rate for Payer: BCBS MT Closed Plan Network |
$15.20
|
| Rate for Payer: BCBS MT HealthLink |
$14.40
|
| Rate for Payer: BCBS MT Medicare |
$14.40
|
| Rate for Payer: BCBS MT POS |
$15.20
|
| Rate for Payer: BCBS MT Traditional |
$16.00
|
| Rate for Payer: Cash Price |
$14.40
|
| Rate for Payer: Cigna Commercial |
$15.20
|
| Rate for Payer: Cigna Medicare |
$14.40
|
| Rate for Payer: Medicaid All Medicaid |
$14.72
|
| Rate for Payer: Medicare All Medicare |
$11.20
|
| Rate for Payer: Monida Allegiance |
$15.20
|
| Rate for Payer: Monida First Choice Health |
$15.52
|
| Rate for Payer: Monida Montana Health Co-op |
$15.20
|
| Rate for Payer: Monida PacificSource |
$15.20
|
|
|
WOUND CULTURE GRAM STAIN
|
Facility
|
IP
|
$120.00
|
|
|
Service Code
|
CPT 87070
|
| Hospital Charge Code |
4087981
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$84.00 |
| Max. Negotiated Rate |
$120.00 |
| Rate for Payer: Aetna Commercial |
$114.00
|
| Rate for Payer: Aetna Medicare |
$108.00
|
| Rate for Payer: BCBS MT CHIP |
$108.00
|
| Rate for Payer: BCBS MT Closed Plan Network |
$114.00
|
| Rate for Payer: BCBS MT HealthLink |
$108.00
|
| Rate for Payer: BCBS MT Medicare |
$108.00
|
| Rate for Payer: BCBS MT POS |
$114.00
|
| Rate for Payer: BCBS MT Traditional |
$120.00
|
| Rate for Payer: Cash Price |
$108.00
|
| Rate for Payer: Cigna Commercial |
$114.00
|
| Rate for Payer: Cigna Medicare |
$108.00
|
| Rate for Payer: Medicaid All Medicaid |
$110.40
|
| Rate for Payer: Medicare All Medicare |
$84.00
|
| Rate for Payer: Monida Allegiance |
$114.00
|
| Rate for Payer: Monida First Choice Health |
$116.40
|
| Rate for Payer: Monida Montana Health Co-op |
$114.00
|
| Rate for Payer: Monida PacificSource |
$114.00
|
|
|
WOUND CULTURE GRAM STAIN
|
Facility
|
OP
|
$120.00
|
|
|
Service Code
|
CPT 87070
|
| Hospital Charge Code |
4087981
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$84.00 |
| Max. Negotiated Rate |
$120.00 |
| Rate for Payer: Aetna Commercial |
$114.00
|
| Rate for Payer: Aetna Medicare |
$108.00
|
| Rate for Payer: BCBS MT CHIP |
$108.00
|
| Rate for Payer: BCBS MT Closed Plan Network |
$114.00
|
| Rate for Payer: BCBS MT HealthLink |
$108.00
|
| Rate for Payer: BCBS MT Medicare |
$108.00
|
| Rate for Payer: BCBS MT POS |
$114.00
|
| Rate for Payer: BCBS MT Traditional |
$120.00
|
| Rate for Payer: Cash Price |
$108.00
|
| Rate for Payer: Cigna Commercial |
$114.00
|
| Rate for Payer: Cigna Medicare |
$108.00
|
| Rate for Payer: Medicaid All Medicaid |
$110.40
|
| Rate for Payer: Medicare All Medicare |
$84.00
|
| Rate for Payer: Monida Allegiance |
$114.00
|
| Rate for Payer: Monida First Choice Health |
$116.40
|
| Rate for Payer: Monida Montana Health Co-op |
$114.00
|
| Rate for Payer: Monida PacificSource |
$114.00
|
|
|
WOUND WASH
|
Facility
|
IP
|
$35.00
|
|
|
Service Code
|
HCPCS A6260
|
| Hospital Charge Code |
8006260
|
|
Hospital Revenue Code
|
521
|
| 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
|
|
|
WOUND WASH
|
Facility
|
OP
|
$35.00
|
|
|
Service Code
|
HCPCS A6260
|
| Hospital Charge Code |
8006260
|
|
Hospital Revenue Code
|
521
|
| 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
|
|
|
WRIST BRACE ELASTIC SM
|
Facility
|
OP
|
$45.00
|
|
|
Service Code
|
HCPCS A4570
|
| Hospital Charge Code |
80030447
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$31.50 |
| Max. Negotiated Rate |
$45.00 |
| Rate for Payer: Aetna Commercial |
$42.75
|
| Rate for Payer: Aetna Medicare |
$40.50
|
| Rate for Payer: BCBS MT CHIP |
$40.50
|
| Rate for Payer: BCBS MT Closed Plan Network |
$42.75
|
| Rate for Payer: BCBS MT HealthLink |
$40.50
|
| Rate for Payer: BCBS MT Medicare |
$40.50
|
| Rate for Payer: BCBS MT POS |
$42.75
|
| Rate for Payer: BCBS MT Traditional |
$45.00
|
| Rate for Payer: Cash Price |
$40.50
|
| Rate for Payer: Cigna Commercial |
$42.75
|
| Rate for Payer: Cigna Medicare |
$40.50
|
| Rate for Payer: Medicaid All Medicaid |
$41.40
|
| Rate for Payer: Medicare All Medicare |
$31.50
|
| Rate for Payer: Monida Allegiance |
$42.75
|
| Rate for Payer: Monida First Choice Health |
$43.65
|
| Rate for Payer: Monida Montana Health Co-op |
$42.75
|
| Rate for Payer: Monida PacificSource |
$42.75
|
|
|
WRIST BRACE ELASTIC SM
|
Facility
|
IP
|
$45.00
|
|
|
Service Code
|
HCPCS A4570
|
| Hospital Charge Code |
80030447
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$31.50 |
| Max. Negotiated Rate |
$45.00 |
| Rate for Payer: Aetna Commercial |
$42.75
|
| Rate for Payer: Aetna Medicare |
$40.50
|
| Rate for Payer: BCBS MT CHIP |
$40.50
|
| Rate for Payer: BCBS MT Closed Plan Network |
$42.75
|
| Rate for Payer: BCBS MT HealthLink |
$40.50
|
| Rate for Payer: BCBS MT Medicare |
$40.50
|
| Rate for Payer: BCBS MT POS |
$42.75
|
| Rate for Payer: BCBS MT Traditional |
$45.00
|
| Rate for Payer: Cash Price |
$40.50
|
| Rate for Payer: Cigna Commercial |
$42.75
|
| Rate for Payer: Cigna Medicare |
$40.50
|
| Rate for Payer: Medicaid All Medicaid |
$41.40
|
| Rate for Payer: Medicare All Medicare |
$31.50
|
| Rate for Payer: Monida Allegiance |
$42.75
|
| Rate for Payer: Monida First Choice Health |
$43.65
|
| Rate for Payer: Monida Montana Health Co-op |
$42.75
|
| Rate for Payer: Monida PacificSource |
$42.75
|
|
|
WRIST/FOREARM SPLINT ELASTIC L
|
Facility
|
OP
|
$34.00
|
|
| Hospital Charge Code |
2893649
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$23.80 |
| Max. Negotiated Rate |
$34.00 |
| Rate for Payer: Aetna Commercial |
$32.30
|
| Rate for Payer: Aetna Medicare |
$30.60
|
| Rate for Payer: BCBS MT CHIP |
$30.60
|
| Rate for Payer: BCBS MT Closed Plan Network |
$32.30
|
| Rate for Payer: BCBS MT HealthLink |
$30.60
|
| Rate for Payer: BCBS MT Medicare |
$30.60
|
| Rate for Payer: BCBS MT POS |
$32.30
|
| Rate for Payer: BCBS MT Traditional |
$34.00
|
| Rate for Payer: Cash Price |
$30.60
|
| Rate for Payer: Cigna Commercial |
$32.30
|
| Rate for Payer: Cigna Medicare |
$30.60
|
| Rate for Payer: Medicaid All Medicaid |
$31.28
|
| Rate for Payer: Medicare All Medicare |
$23.80
|
| Rate for Payer: Monida Allegiance |
$32.30
|
| Rate for Payer: Monida First Choice Health |
$32.98
|
| Rate for Payer: Monida Montana Health Co-op |
$32.30
|
| Rate for Payer: Monida PacificSource |
$32.30
|
|
|
WRIST/FOREARM SPLINT ELASTIC L
|
Facility
|
IP
|
$34.00
|
|
| Hospital Charge Code |
2893649
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$23.80 |
| Max. Negotiated Rate |
$34.00 |
| Rate for Payer: Aetna Commercial |
$32.30
|
| Rate for Payer: Aetna Medicare |
$30.60
|
| Rate for Payer: BCBS MT CHIP |
$30.60
|
| Rate for Payer: BCBS MT Closed Plan Network |
$32.30
|
| Rate for Payer: BCBS MT HealthLink |
$30.60
|
| Rate for Payer: BCBS MT Medicare |
$30.60
|
| Rate for Payer: BCBS MT POS |
$32.30
|
| Rate for Payer: BCBS MT Traditional |
$34.00
|
| Rate for Payer: Cash Price |
$30.60
|
| Rate for Payer: Cigna Commercial |
$32.30
|
| Rate for Payer: Cigna Medicare |
$30.60
|
| Rate for Payer: Medicaid All Medicaid |
$31.28
|
| Rate for Payer: Medicare All Medicare |
$23.80
|
| Rate for Payer: Monida Allegiance |
$32.30
|
| Rate for Payer: Monida First Choice Health |
$32.98
|
| Rate for Payer: Monida Montana Health Co-op |
$32.30
|
| Rate for Payer: Monida PacificSource |
$32.30
|
|
|
WRIST & FOREARM SUPP LT/MED
|
Facility
|
IP
|
$36.00
|
|
| Hospital Charge Code |
2893645
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$25.20 |
| Max. Negotiated Rate |
$36.00 |
| Rate for Payer: Aetna Commercial |
$34.20
|
| Rate for Payer: Aetna Medicare |
$32.40
|
| Rate for Payer: BCBS MT CHIP |
$32.40
|
| Rate for Payer: BCBS MT Closed Plan Network |
$34.20
|
| Rate for Payer: BCBS MT HealthLink |
$32.40
|
| Rate for Payer: BCBS MT Medicare |
$32.40
|
| Rate for Payer: BCBS MT POS |
$34.20
|
| Rate for Payer: BCBS MT Traditional |
$36.00
|
| Rate for Payer: Cash Price |
$32.40
|
| Rate for Payer: Cigna Commercial |
$34.20
|
| Rate for Payer: Cigna Medicare |
$32.40
|
| Rate for Payer: Medicaid All Medicaid |
$33.12
|
| Rate for Payer: Medicare All Medicare |
$25.20
|
| Rate for Payer: Monida Allegiance |
$34.20
|
| Rate for Payer: Monida First Choice Health |
$34.92
|
| Rate for Payer: Monida Montana Health Co-op |
$34.20
|
| Rate for Payer: Monida PacificSource |
$34.20
|
|
|
WRIST & FOREARM SUPP LT/MED
|
Facility
|
OP
|
$36.00
|
|
| Hospital Charge Code |
2893645
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$25.20 |
| Max. Negotiated Rate |
$36.00 |
| Rate for Payer: Aetna Commercial |
$34.20
|
| Rate for Payer: Aetna Medicare |
$32.40
|
| Rate for Payer: BCBS MT CHIP |
$32.40
|
| Rate for Payer: BCBS MT Closed Plan Network |
$34.20
|
| Rate for Payer: BCBS MT HealthLink |
$32.40
|
| Rate for Payer: BCBS MT Medicare |
$32.40
|
| Rate for Payer: BCBS MT POS |
$34.20
|
| Rate for Payer: BCBS MT Traditional |
$36.00
|
| Rate for Payer: Cash Price |
$32.40
|
| Rate for Payer: Cigna Commercial |
$34.20
|
| Rate for Payer: Cigna Medicare |
$32.40
|
| Rate for Payer: Medicaid All Medicaid |
$33.12
|
| Rate for Payer: Medicare All Medicare |
$25.20
|
| Rate for Payer: Monida Allegiance |
$34.20
|
| Rate for Payer: Monida First Choice Health |
$34.92
|
| Rate for Payer: Monida Montana Health Co-op |
$34.20
|
| Rate for Payer: Monida PacificSource |
$34.20
|
|
|
WRIST & FOREARM SUPP LT/SM
|
Facility
|
IP
|
$32.00
|
|
| Hospital Charge Code |
2893643
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$22.40 |
| Max. Negotiated Rate |
$32.00 |
| Rate for Payer: Aetna Commercial |
$30.40
|
| Rate for Payer: Aetna Medicare |
$28.80
|
| Rate for Payer: BCBS MT CHIP |
$28.80
|
| Rate for Payer: BCBS MT Closed Plan Network |
$30.40
|
| Rate for Payer: BCBS MT HealthLink |
$28.80
|
| Rate for Payer: BCBS MT Medicare |
$28.80
|
| Rate for Payer: BCBS MT POS |
$30.40
|
| Rate for Payer: BCBS MT Traditional |
$32.00
|
| Rate for Payer: Cash Price |
$28.80
|
| Rate for Payer: Cigna Commercial |
$30.40
|
| Rate for Payer: Cigna Medicare |
$28.80
|
| Rate for Payer: Medicaid All Medicaid |
$29.44
|
| Rate for Payer: Medicare All Medicare |
$22.40
|
| Rate for Payer: Monida Allegiance |
$30.40
|
| Rate for Payer: Monida First Choice Health |
$31.04
|
| Rate for Payer: Monida Montana Health Co-op |
$30.40
|
| Rate for Payer: Monida PacificSource |
$30.40
|
|
|
WRIST & FOREARM SUPP LT/SM
|
Facility
|
OP
|
$32.00
|
|
| Hospital Charge Code |
2893643
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$22.40 |
| Max. Negotiated Rate |
$32.00 |
| Rate for Payer: Aetna Commercial |
$30.40
|
| Rate for Payer: Aetna Medicare |
$28.80
|
| Rate for Payer: BCBS MT CHIP |
$28.80
|
| Rate for Payer: BCBS MT Closed Plan Network |
$30.40
|
| Rate for Payer: BCBS MT HealthLink |
$28.80
|
| Rate for Payer: BCBS MT Medicare |
$28.80
|
| Rate for Payer: BCBS MT POS |
$30.40
|
| Rate for Payer: BCBS MT Traditional |
$32.00
|
| Rate for Payer: Cash Price |
$28.80
|
| Rate for Payer: Cigna Commercial |
$30.40
|
| Rate for Payer: Cigna Medicare |
$28.80
|
| Rate for Payer: Medicaid All Medicaid |
$29.44
|
| Rate for Payer: Medicare All Medicare |
$22.40
|
| Rate for Payer: Monida Allegiance |
$30.40
|
| Rate for Payer: Monida First Choice Health |
$31.04
|
| Rate for Payer: Monida Montana Health Co-op |
$30.40
|
| Rate for Payer: Monida PacificSource |
$30.40
|
|
|
WRIST & FOREARM SUPP LT XLG
|
Facility
|
IP
|
$42.00
|
|
| Hospital Charge Code |
2893648
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$29.40 |
| Max. Negotiated Rate |
$42.00 |
| Rate for Payer: Aetna Commercial |
$39.90
|
| Rate for Payer: Aetna Medicare |
$37.80
|
| Rate for Payer: BCBS MT CHIP |
$37.80
|
| Rate for Payer: BCBS MT Closed Plan Network |
$39.90
|
| Rate for Payer: BCBS MT HealthLink |
$37.80
|
| Rate for Payer: BCBS MT Medicare |
$37.80
|
| Rate for Payer: BCBS MT POS |
$39.90
|
| Rate for Payer: BCBS MT Traditional |
$42.00
|
| Rate for Payer: Cash Price |
$37.80
|
| Rate for Payer: Cigna Commercial |
$39.90
|
| Rate for Payer: Cigna Medicare |
$37.80
|
| Rate for Payer: Medicaid All Medicaid |
$38.64
|
| Rate for Payer: Medicare All Medicare |
$29.40
|
| Rate for Payer: Monida Allegiance |
$39.90
|
| Rate for Payer: Monida First Choice Health |
$40.74
|
| Rate for Payer: Monida Montana Health Co-op |
$39.90
|
| Rate for Payer: Monida PacificSource |
$39.90
|
|
|
WRIST & FOREARM SUPP LT XLG
|
Facility
|
OP
|
$42.00
|
|
| Hospital Charge Code |
2893648
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$29.40 |
| Max. Negotiated Rate |
$42.00 |
| Rate for Payer: Aetna Commercial |
$39.90
|
| Rate for Payer: Aetna Medicare |
$37.80
|
| Rate for Payer: BCBS MT CHIP |
$37.80
|
| Rate for Payer: BCBS MT Closed Plan Network |
$39.90
|
| Rate for Payer: BCBS MT HealthLink |
$37.80
|
| Rate for Payer: BCBS MT Medicare |
$37.80
|
| Rate for Payer: BCBS MT POS |
$39.90
|
| Rate for Payer: BCBS MT Traditional |
$42.00
|
| Rate for Payer: Cash Price |
$37.80
|
| Rate for Payer: Cigna Commercial |
$39.90
|
| Rate for Payer: Cigna Medicare |
$37.80
|
| Rate for Payer: Medicaid All Medicaid |
$38.64
|
| Rate for Payer: Medicare All Medicare |
$29.40
|
| Rate for Payer: Monida Allegiance |
$39.90
|
| Rate for Payer: Monida First Choice Health |
$40.74
|
| Rate for Payer: Monida Montana Health Co-op |
$39.90
|
| Rate for Payer: Monida PacificSource |
$39.90
|
|
|
WRIST & FOREARM SUPPORT LT/LG
|
Facility
|
IP
|
$36.00
|
|
| Hospital Charge Code |
2893646
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$25.20 |
| Max. Negotiated Rate |
$36.00 |
| Rate for Payer: Aetna Commercial |
$34.20
|
| Rate for Payer: Aetna Medicare |
$32.40
|
| Rate for Payer: BCBS MT CHIP |
$32.40
|
| Rate for Payer: BCBS MT Closed Plan Network |
$34.20
|
| Rate for Payer: BCBS MT HealthLink |
$32.40
|
| Rate for Payer: BCBS MT Medicare |
$32.40
|
| Rate for Payer: BCBS MT POS |
$34.20
|
| Rate for Payer: BCBS MT Traditional |
$36.00
|
| Rate for Payer: Cash Price |
$32.40
|
| Rate for Payer: Cigna Commercial |
$34.20
|
| Rate for Payer: Cigna Medicare |
$32.40
|
| Rate for Payer: Medicaid All Medicaid |
$33.12
|
| Rate for Payer: Medicare All Medicare |
$25.20
|
| Rate for Payer: Monida Allegiance |
$34.20
|
| Rate for Payer: Monida First Choice Health |
$34.92
|
| Rate for Payer: Monida Montana Health Co-op |
$34.20
|
| Rate for Payer: Monida PacificSource |
$34.20
|
|
|
WRIST & FOREARM SUPPORT LT/LG
|
Facility
|
OP
|
$36.00
|
|
| Hospital Charge Code |
2893646
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$25.20 |
| Max. Negotiated Rate |
$36.00 |
| Rate for Payer: Aetna Commercial |
$34.20
|
| Rate for Payer: Aetna Medicare |
$32.40
|
| Rate for Payer: BCBS MT CHIP |
$32.40
|
| Rate for Payer: BCBS MT Closed Plan Network |
$34.20
|
| Rate for Payer: BCBS MT HealthLink |
$32.40
|
| Rate for Payer: BCBS MT Medicare |
$32.40
|
| Rate for Payer: BCBS MT POS |
$34.20
|
| Rate for Payer: BCBS MT Traditional |
$36.00
|
| Rate for Payer: Cash Price |
$32.40
|
| Rate for Payer: Cigna Commercial |
$34.20
|
| Rate for Payer: Cigna Medicare |
$32.40
|
| Rate for Payer: Medicaid All Medicaid |
$33.12
|
| Rate for Payer: Medicare All Medicare |
$25.20
|
| Rate for Payer: Monida Allegiance |
$34.20
|
| Rate for Payer: Monida First Choice Health |
$34.92
|
| Rate for Payer: Monida Montana Health Co-op |
$34.20
|
| Rate for Payer: Monida PacificSource |
$34.20
|
|
|
WRIST & FOREARM SUPP RT
|
Facility
|
OP
|
$36.00
|
|
|
Service Code
|
HCPCS A4570
|
| Hospital Charge Code |
2862607
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$25.20 |
| Max. Negotiated Rate |
$36.00 |
| Rate for Payer: Aetna Commercial |
$34.20
|
| Rate for Payer: Aetna Medicare |
$32.40
|
| Rate for Payer: BCBS MT CHIP |
$32.40
|
| Rate for Payer: BCBS MT Closed Plan Network |
$34.20
|
| Rate for Payer: BCBS MT HealthLink |
$32.40
|
| Rate for Payer: BCBS MT Medicare |
$32.40
|
| Rate for Payer: BCBS MT POS |
$34.20
|
| Rate for Payer: BCBS MT Traditional |
$36.00
|
| Rate for Payer: Cash Price |
$32.40
|
| Rate for Payer: Cigna Commercial |
$34.20
|
| Rate for Payer: Cigna Medicare |
$32.40
|
| Rate for Payer: Medicaid All Medicaid |
$33.12
|
| Rate for Payer: Medicare All Medicare |
$25.20
|
| Rate for Payer: Monida Allegiance |
$34.20
|
| Rate for Payer: Monida First Choice Health |
$34.92
|
| Rate for Payer: Monida Montana Health Co-op |
$34.20
|
| Rate for Payer: Monida PacificSource |
$34.20
|
|
|
WRIST & FOREARM SUPP RT
|
Facility
|
IP
|
$36.00
|
|
|
Service Code
|
HCPCS A4570
|
| Hospital Charge Code |
2862607
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$25.20 |
| Max. Negotiated Rate |
$36.00 |
| Rate for Payer: Aetna Commercial |
$34.20
|
| Rate for Payer: Aetna Medicare |
$32.40
|
| Rate for Payer: BCBS MT CHIP |
$32.40
|
| Rate for Payer: BCBS MT Closed Plan Network |
$34.20
|
| Rate for Payer: BCBS MT HealthLink |
$32.40
|
| Rate for Payer: BCBS MT Medicare |
$32.40
|
| Rate for Payer: BCBS MT POS |
$34.20
|
| Rate for Payer: BCBS MT Traditional |
$36.00
|
| Rate for Payer: Cash Price |
$32.40
|
| Rate for Payer: Cigna Commercial |
$34.20
|
| Rate for Payer: Cigna Medicare |
$32.40
|
| Rate for Payer: Medicaid All Medicaid |
$33.12
|
| Rate for Payer: Medicare All Medicare |
$25.20
|
| Rate for Payer: Monida Allegiance |
$34.20
|
| Rate for Payer: Monida First Choice Health |
$34.92
|
| Rate for Payer: Monida Montana Health Co-op |
$34.20
|
| Rate for Payer: Monida PacificSource |
$34.20
|
|
|
WRIST & FOREARM SUPP RT/LG
|
Facility
|
OP
|
$36.00
|
|
| Hospital Charge Code |
2893642
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$25.20 |
| Max. Negotiated Rate |
$36.00 |
| Rate for Payer: Aetna Commercial |
$34.20
|
| Rate for Payer: Aetna Medicare |
$32.40
|
| Rate for Payer: BCBS MT CHIP |
$32.40
|
| Rate for Payer: BCBS MT Closed Plan Network |
$34.20
|
| Rate for Payer: BCBS MT HealthLink |
$32.40
|
| Rate for Payer: BCBS MT Medicare |
$32.40
|
| Rate for Payer: BCBS MT POS |
$34.20
|
| Rate for Payer: BCBS MT Traditional |
$36.00
|
| Rate for Payer: Cash Price |
$32.40
|
| Rate for Payer: Cigna Commercial |
$34.20
|
| Rate for Payer: Cigna Medicare |
$32.40
|
| Rate for Payer: Medicaid All Medicaid |
$33.12
|
| Rate for Payer: Medicare All Medicare |
$25.20
|
| Rate for Payer: Monida Allegiance |
$34.20
|
| Rate for Payer: Monida First Choice Health |
$34.92
|
| Rate for Payer: Monida Montana Health Co-op |
$34.20
|
| Rate for Payer: Monida PacificSource |
$34.20
|
|
|
WRIST & FOREARM SUPP RT/LG
|
Facility
|
IP
|
$36.00
|
|
| Hospital Charge Code |
2893642
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$25.20 |
| Max. Negotiated Rate |
$36.00 |
| Rate for Payer: Aetna Commercial |
$34.20
|
| Rate for Payer: Aetna Medicare |
$32.40
|
| Rate for Payer: BCBS MT CHIP |
$32.40
|
| Rate for Payer: BCBS MT Closed Plan Network |
$34.20
|
| Rate for Payer: BCBS MT HealthLink |
$32.40
|
| Rate for Payer: BCBS MT Medicare |
$32.40
|
| Rate for Payer: BCBS MT POS |
$34.20
|
| Rate for Payer: BCBS MT Traditional |
$36.00
|
| Rate for Payer: Cash Price |
$32.40
|
| Rate for Payer: Cigna Commercial |
$34.20
|
| Rate for Payer: Cigna Medicare |
$32.40
|
| Rate for Payer: Medicaid All Medicaid |
$33.12
|
| Rate for Payer: Medicare All Medicare |
$25.20
|
| Rate for Payer: Monida Allegiance |
$34.20
|
| Rate for Payer: Monida First Choice Health |
$34.92
|
| Rate for Payer: Monida Montana Health Co-op |
$34.20
|
| Rate for Payer: Monida PacificSource |
$34.20
|
|
