|
CARVEDILOL TAB [6.25 MG]
|
Facility
|
OP
|
$8.00
|
|
|
Service Code
|
HCPCS J8499
|
| 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
|
IP
|
$8.00
|
|
|
Service Code
|
HCPCS J8499
|
| 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
|
|
|
CA SCREEN; PELVIC/BREAST EXAM
|
Facility
|
OP
|
$165.00
|
|
|
Service Code
|
HCPCS G0101
|
| Hospital Charge Code |
80000101
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$115.50 |
| Max. Negotiated Rate |
$165.00 |
| Rate for Payer: Aetna Commercial |
$156.75
|
| Rate for Payer: Aetna Medicare |
$148.50
|
| Rate for Payer: BCBS MT CHIP |
$148.50
|
| Rate for Payer: BCBS MT Closed Plan Network |
$156.75
|
| Rate for Payer: BCBS MT HealthLink |
$148.50
|
| Rate for Payer: BCBS MT Medicare |
$148.50
|
| Rate for Payer: BCBS MT POS |
$156.75
|
| Rate for Payer: BCBS MT Traditional |
$165.00
|
| Rate for Payer: Cash Price |
$148.50
|
| Rate for Payer: Cigna Commercial |
$156.75
|
| Rate for Payer: Cigna Medicare |
$148.50
|
| Rate for Payer: Medicaid All Medicaid |
$151.80
|
| Rate for Payer: Medicare All Medicare |
$115.50
|
| Rate for Payer: Monida Allegiance |
$156.75
|
| Rate for Payer: Monida First Choice Health |
$160.05
|
| Rate for Payer: Monida Montana Health Co-op |
$156.75
|
| Rate for Payer: Monida PacificSource |
$156.75
|
|
|
CA SCREEN; PELVIC/BREAST EXAM
|
Facility
|
IP
|
$165.00
|
|
|
Service Code
|
HCPCS G0101
|
| Hospital Charge Code |
80000101
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$115.50 |
| Max. Negotiated Rate |
$165.00 |
| Rate for Payer: Aetna Commercial |
$156.75
|
| Rate for Payer: Aetna Medicare |
$148.50
|
| Rate for Payer: BCBS MT CHIP |
$148.50
|
| Rate for Payer: BCBS MT Closed Plan Network |
$156.75
|
| Rate for Payer: BCBS MT HealthLink |
$148.50
|
| Rate for Payer: BCBS MT Medicare |
$148.50
|
| Rate for Payer: BCBS MT POS |
$156.75
|
| Rate for Payer: BCBS MT Traditional |
$165.00
|
| Rate for Payer: Cash Price |
$148.50
|
| Rate for Payer: Cigna Commercial |
$156.75
|
| Rate for Payer: Cigna Medicare |
$148.50
|
| Rate for Payer: Medicaid All Medicaid |
$151.80
|
| Rate for Payer: Medicare All Medicare |
$115.50
|
| Rate for Payer: Monida Allegiance |
$156.75
|
| Rate for Payer: Monida First Choice Health |
$160.05
|
| Rate for Payer: Monida Montana Health Co-op |
$156.75
|
| Rate for Payer: Monida PacificSource |
$156.75
|
|
|
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
|
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 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 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 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 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
|
|
|
CAST SHOE M MALE
|
Facility
|
OP
|
$24.00
|
|
| Hospital Charge Code |
2893225
|
|
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 MALE
|
Facility
|
IP
|
$24.00
|
|
| Hospital Charge Code |
2893225
|
|
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 S FEMALE
|
Facility
|
OP
|
$27.00
|
|
| Hospital Charge Code |
2893220
|
|
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 S FEMALE
|
Facility
|
IP
|
$27.00
|
|
| Hospital Charge Code |
2893220
|
|
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 S MALE
|
Facility
|
IP
|
$23.00
|
|
| Hospital Charge Code |
2893224
|
|
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 MALE
|
Facility
|
OP
|
$23.00
|
|
| Hospital Charge Code |
2893224
|
|
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
|
OP
|
$24.00
|
|
| Hospital Charge Code |
2893227
|
|
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 XL MALE
|
Facility
|
IP
|
$24.00
|
|
| Hospital Charge Code |
2893227
|
|
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 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 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 MALE
|
Facility
|
IP
|
$24.00
|
|
| Hospital Charge Code |
2893223
|
|
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
|
|
