|
COLLES SPLINT MED W/PAD
|
Facility
OP
|
$21.00
|
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$14.70 |
| Max. Negotiated Rate |
$21.00 |
| Rate for Payer: AETNA Commercial |
$19.95
|
| Rate for Payer: AETNA Medicare |
$18.90
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$19.95
|
| Rate for Payer: BCBS Healthlink |
$18.90
|
| Rate for Payer: BCBS HMK CHIP |
$18.90
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$18.90
|
| Rate for Payer: BCBS POS |
$19.95
|
| Rate for Payer: BCBS Traditional |
$21.00
|
| Rate for Payer: CASH_PRICE |
$16.80
|
| Rate for Payer: CIGNA Commercial |
$19.95
|
| Rate for Payer: CIGNA Medicare |
$18.90
|
| Rate for Payer: HUMANA Commercial |
$18.90
|
| Rate for Payer: MEDICAID Medicaid |
$19.32
|
| Rate for Payer: MEDICARE Medicare |
$14.70
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$19.95
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$20.37
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$19.95
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$19.95
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$17.85
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$16.80
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$16.80
|
|
|
COLLES SPLINT RT/LG W/PAD
|
Facility
OP
|
$21.00
|
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$14.70 |
| Max. Negotiated Rate |
$21.00 |
| Rate for Payer: AETNA Commercial |
$19.95
|
| Rate for Payer: AETNA Medicare |
$18.90
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$19.95
|
| Rate for Payer: BCBS Healthlink |
$18.90
|
| Rate for Payer: BCBS HMK CHIP |
$18.90
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$18.90
|
| Rate for Payer: BCBS POS |
$19.95
|
| Rate for Payer: BCBS Traditional |
$21.00
|
| Rate for Payer: CASH_PRICE |
$16.80
|
| Rate for Payer: CIGNA Commercial |
$19.95
|
| Rate for Payer: CIGNA Medicare |
$18.90
|
| Rate for Payer: HUMANA Commercial |
$18.90
|
| Rate for Payer: MEDICAID Medicaid |
$19.32
|
| Rate for Payer: MEDICARE Medicare |
$14.70
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$19.95
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$20.37
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$19.95
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$19.95
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$17.85
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$16.80
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$16.80
|
|
|
COLLES SPLINT RT/LG W/PAD
|
Facility
IP
|
$21.00
|
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$14.70 |
| Max. Negotiated Rate |
$21.00 |
| Rate for Payer: BCBS HMK CHIP |
$18.90
|
| Rate for Payer: AETNA Commercial |
$19.95
|
| Rate for Payer: AETNA Medicare |
$18.90
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$19.95
|
| Rate for Payer: BCBS Healthlink |
$18.90
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$18.90
|
| Rate for Payer: BCBS POS |
$19.95
|
| Rate for Payer: BCBS Traditional |
$21.00
|
| Rate for Payer: CASH_PRICE |
$16.80
|
| Rate for Payer: CIGNA Commercial |
$19.95
|
| Rate for Payer: CIGNA Medicare |
$18.90
|
| Rate for Payer: HUMANA Commercial |
$18.90
|
| Rate for Payer: MEDICAID Medicaid |
$19.32
|
| Rate for Payer: MEDICARE Medicare |
$14.70
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$19.95
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$20.37
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$19.95
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$19.95
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$17.85
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$16.80
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$16.80
|
|
|
COLLES SPLINT RT/MD W/PAD
|
Facility
OP
|
$21.00
|
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$14.70 |
| Max. Negotiated Rate |
$21.00 |
| Rate for Payer: AETNA Commercial |
$19.95
|
| Rate for Payer: AETNA Medicare |
$18.90
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$19.95
|
| Rate for Payer: BCBS Healthlink |
$18.90
|
| Rate for Payer: BCBS HMK CHIP |
$18.90
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$18.90
|
| Rate for Payer: BCBS POS |
$19.95
|
| Rate for Payer: BCBS Traditional |
$21.00
|
| Rate for Payer: CASH_PRICE |
$16.80
|
| Rate for Payer: CIGNA Commercial |
$19.95
|
| Rate for Payer: CIGNA Medicare |
$18.90
|
| Rate for Payer: HUMANA Commercial |
$18.90
|
| Rate for Payer: MEDICAID Medicaid |
$19.32
|
| Rate for Payer: MEDICARE Medicare |
$14.70
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$19.95
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$20.37
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$19.95
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$19.95
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$17.85
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$16.80
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$16.80
|
|
|
COLLES SPLINT RT/MD W/PAD
|
Facility
IP
|
$21.00
|
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$14.70 |
| Max. Negotiated Rate |
$21.00 |
| Rate for Payer: AETNA Commercial |
$19.95
|
| Rate for Payer: AETNA Medicare |
$18.90
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$19.95
|
| Rate for Payer: BCBS Healthlink |
$18.90
|
| Rate for Payer: BCBS HMK CHIP |
$18.90
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$18.90
|
| Rate for Payer: BCBS POS |
$19.95
|
| Rate for Payer: BCBS Traditional |
$21.00
|
| Rate for Payer: CASH_PRICE |
$16.80
|
| Rate for Payer: CIGNA Commercial |
$19.95
|
| Rate for Payer: CIGNA Medicare |
$18.90
|
| Rate for Payer: HUMANA Commercial |
$18.90
|
| Rate for Payer: MEDICAID Medicaid |
$19.32
|
| Rate for Payer: MEDICARE Medicare |
$14.70
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$19.95
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$20.37
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$19.95
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$19.95
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$17.85
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$16.80
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$16.80
|
|
|
COMBIGAN OPHTH SOLN 0.2%-0.5%-NF
|
Facility
OP
|
$563.40
|
|
| Hospital Charge Code |
20230124
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$394.38 |
| Max. Negotiated Rate |
$563.40 |
| Rate for Payer: AETNA Commercial |
$535.23
|
| Rate for Payer: AETNA Medicare |
$507.06
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$535.23
|
| Rate for Payer: BCBS Healthlink |
$507.06
|
| Rate for Payer: BCBS HMK CHIP |
$507.06
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$507.06
|
| Rate for Payer: BCBS POS |
$535.23
|
| Rate for Payer: BCBS Traditional |
$563.40
|
| Rate for Payer: CASH_PRICE |
$450.72
|
| Rate for Payer: CIGNA Commercial |
$535.23
|
| Rate for Payer: CIGNA Medicare |
$507.06
|
| Rate for Payer: HUMANA Commercial |
$507.06
|
| Rate for Payer: MEDICAID Medicaid |
$518.33
|
| Rate for Payer: MEDICARE Medicare |
$394.38
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$535.23
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$546.50
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$535.23
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$535.23
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$478.89
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$450.72
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$450.72
|
|
|
COMBIGAN OPHTH SOLN 0.2%-0.5%-NF
|
Facility
IP
|
$563.40
|
|
| Hospital Charge Code |
20230124
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$394.38 |
| Max. Negotiated Rate |
$563.40 |
| Rate for Payer: BCBS HMK CHIP |
$507.06
|
| Rate for Payer: AETNA Commercial |
$535.23
|
| Rate for Payer: AETNA Medicare |
$507.06
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$535.23
|
| Rate for Payer: BCBS Healthlink |
$507.06
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$507.06
|
| Rate for Payer: BCBS POS |
$535.23
|
| Rate for Payer: BCBS Traditional |
$563.40
|
| Rate for Payer: CASH_PRICE |
$450.72
|
| Rate for Payer: CIGNA Commercial |
$535.23
|
| Rate for Payer: CIGNA Medicare |
$507.06
|
| Rate for Payer: HUMANA Commercial |
$507.06
|
| Rate for Payer: MEDICAID Medicaid |
$518.33
|
| Rate for Payer: MEDICARE Medicare |
$394.38
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$535.23
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$546.50
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$535.23
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$535.23
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$478.89
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$450.72
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$450.72
|
|
|
COMFORT FORM WRIST LT XLG
|
Facility
OP
|
$30.00
|
|
| Hospital Charge Code |
20221105
|
|
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 CLOSED PLAN NETWORK |
$28.50
|
| Rate for Payer: BCBS Healthlink |
$27.00
|
| Rate for Payer: BCBS HMK CHIP |
$27.00
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$27.00
|
| Rate for Payer: BCBS POS |
$28.50
|
| Rate for Payer: BCBS Traditional |
$30.00
|
| Rate for Payer: CASH_PRICE |
$24.00
|
| Rate for Payer: CIGNA Commercial |
$28.50
|
| Rate for Payer: CIGNA Medicare |
$27.00
|
| Rate for Payer: HUMANA Commercial |
$27.00
|
| Rate for Payer: MEDICAID Medicaid |
$27.60
|
| Rate for Payer: MEDICARE Medicare |
$21.00
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$28.50
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$29.10
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$28.50
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$28.50
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$25.50
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$24.00
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$24.00
|
|
|
COMFORT FORM WRIST LT XLG
|
Facility
IP
|
$30.00
|
|
| Hospital Charge Code |
20221105
|
|
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 CLOSED PLAN NETWORK |
$28.50
|
| Rate for Payer: BCBS Healthlink |
$27.00
|
| Rate for Payer: BCBS HMK CHIP |
$27.00
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$27.00
|
| Rate for Payer: BCBS POS |
$28.50
|
| Rate for Payer: BCBS Traditional |
$30.00
|
| Rate for Payer: CASH_PRICE |
$24.00
|
| Rate for Payer: CIGNA Commercial |
$28.50
|
| Rate for Payer: CIGNA Medicare |
$27.00
|
| Rate for Payer: HUMANA Commercial |
$27.00
|
| Rate for Payer: MEDICAID Medicaid |
$27.60
|
| Rate for Payer: MEDICARE Medicare |
$21.00
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$28.50
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$29.10
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$28.50
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$28.50
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$25.50
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$24.00
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$24.00
|
|
|
COMFORT FORM WRIST RT L
|
Facility
IP
|
$30.00
|
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$21.00 |
| Max. Negotiated Rate |
$30.00 |
| Rate for Payer: BCBS HMK CHIP |
$27.00
|
| Rate for Payer: AETNA Commercial |
$28.50
|
| Rate for Payer: AETNA Medicare |
$27.00
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$28.50
|
| Rate for Payer: BCBS Healthlink |
$27.00
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$27.00
|
| Rate for Payer: BCBS POS |
$28.50
|
| Rate for Payer: BCBS Traditional |
$30.00
|
| Rate for Payer: CASH_PRICE |
$24.00
|
| Rate for Payer: CIGNA Commercial |
$28.50
|
| Rate for Payer: CIGNA Medicare |
$27.00
|
| Rate for Payer: HUMANA Commercial |
$27.00
|
| Rate for Payer: MEDICAID Medicaid |
$27.60
|
| Rate for Payer: MEDICARE Medicare |
$21.00
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$28.50
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$29.10
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$28.50
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$28.50
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$25.50
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$24.00
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$24.00
|
|
|
COMFORT FORM WRIST RT L
|
Facility
OP
|
$30.00
|
|
| Hospital Charge Code |
20221105
|
|
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 CLOSED PLAN NETWORK |
$28.50
|
| Rate for Payer: BCBS Healthlink |
$27.00
|
| Rate for Payer: BCBS HMK CHIP |
$27.00
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$27.00
|
| Rate for Payer: BCBS POS |
$28.50
|
| Rate for Payer: BCBS Traditional |
$30.00
|
| Rate for Payer: CASH_PRICE |
$24.00
|
| Rate for Payer: CIGNA Commercial |
$28.50
|
| Rate for Payer: CIGNA Medicare |
$27.00
|
| Rate for Payer: HUMANA Commercial |
$27.00
|
| Rate for Payer: MEDICAID Medicaid |
$27.60
|
| Rate for Payer: MEDICARE Medicare |
$21.00
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$28.50
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$29.10
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$28.50
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$28.50
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$25.50
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$24.00
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$24.00
|
|
|
COMFORT FORM WRIST RT M
|
Facility
IP
|
$30.00
|
|
| Hospital Charge Code |
20221105
|
|
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 CLOSED PLAN NETWORK |
$28.50
|
| Rate for Payer: BCBS Healthlink |
$27.00
|
| Rate for Payer: BCBS HMK CHIP |
$27.00
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$27.00
|
| Rate for Payer: BCBS POS |
$28.50
|
| Rate for Payer: BCBS Traditional |
$30.00
|
| Rate for Payer: CASH_PRICE |
$24.00
|
| Rate for Payer: CIGNA Commercial |
$28.50
|
| Rate for Payer: CIGNA Medicare |
$27.00
|
| Rate for Payer: HUMANA Commercial |
$27.00
|
| Rate for Payer: MEDICAID Medicaid |
$27.60
|
| Rate for Payer: MEDICARE Medicare |
$21.00
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$28.50
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$29.10
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$28.50
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$28.50
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$25.50
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$24.00
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$24.00
|
|
|
COMFORT FORM WRIST RT M
|
Facility
OP
|
$30.00
|
|
| Hospital Charge Code |
20221105
|
|
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 CLOSED PLAN NETWORK |
$28.50
|
| Rate for Payer: BCBS Healthlink |
$27.00
|
| Rate for Payer: BCBS HMK CHIP |
$27.00
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$27.00
|
| Rate for Payer: BCBS POS |
$28.50
|
| Rate for Payer: BCBS Traditional |
$30.00
|
| Rate for Payer: CASH_PRICE |
$24.00
|
| Rate for Payer: CIGNA Commercial |
$28.50
|
| Rate for Payer: CIGNA Medicare |
$27.00
|
| Rate for Payer: HUMANA Commercial |
$27.00
|
| Rate for Payer: MEDICAID Medicaid |
$27.60
|
| Rate for Payer: MEDICARE Medicare |
$21.00
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$28.50
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$29.10
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$28.50
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$28.50
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$25.50
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$24.00
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$24.00
|
|
|
COMFORT FORM WRIST RT S
|
Facility
IP
|
$37.00
|
|
|
Service Code
|
CPT L3908
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$25.90 |
| Max. Negotiated Rate |
$37.00 |
| Rate for Payer: BCBS HMK CHIP |
$33.30
|
| Rate for Payer: AETNA Commercial |
$35.15
|
| Rate for Payer: AETNA Medicare |
$33.30
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$35.15
|
| Rate for Payer: BCBS Healthlink |
$33.30
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$33.30
|
| Rate for Payer: BCBS POS |
$35.15
|
| Rate for Payer: BCBS Traditional |
$37.00
|
| Rate for Payer: CASH_PRICE |
$29.60
|
| Rate for Payer: CIGNA Commercial |
$35.15
|
| Rate for Payer: CIGNA Medicare |
$33.30
|
| Rate for Payer: HUMANA Commercial |
$33.30
|
| Rate for Payer: MEDICAID Medicaid |
$34.04
|
| Rate for Payer: MEDICARE Medicare |
$25.90
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$35.15
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$35.89
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$35.15
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$35.15
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$31.45
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$29.60
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$29.60
|
|
|
COMFORT FORM WRIST RT S
|
Facility
OP
|
$37.00
|
|
|
Service Code
|
CPT L3908
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$25.90 |
| Max. Negotiated Rate |
$37.00 |
| Rate for Payer: AETNA Commercial |
$35.15
|
| Rate for Payer: AETNA Medicare |
$33.30
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$35.15
|
| Rate for Payer: BCBS Healthlink |
$33.30
|
| Rate for Payer: BCBS HMK CHIP |
$33.30
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$33.30
|
| Rate for Payer: BCBS POS |
$35.15
|
| Rate for Payer: BCBS Traditional |
$37.00
|
| Rate for Payer: CASH_PRICE |
$29.60
|
| Rate for Payer: CIGNA Commercial |
$35.15
|
| Rate for Payer: CIGNA Medicare |
$33.30
|
| Rate for Payer: HUMANA Commercial |
$33.30
|
| Rate for Payer: MEDICAID Medicaid |
$34.04
|
| Rate for Payer: MEDICARE Medicare |
$25.90
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$35.15
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$35.89
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$35.15
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$35.15
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$31.45
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$29.60
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$29.60
|
|
|
COMFORT FORM WRIST RT XLG
|
Facility
OP
|
$30.00
|
|
| Hospital Charge Code |
20221105
|
|
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 CLOSED PLAN NETWORK |
$28.50
|
| Rate for Payer: BCBS Healthlink |
$27.00
|
| Rate for Payer: BCBS HMK CHIP |
$27.00
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$27.00
|
| Rate for Payer: BCBS POS |
$28.50
|
| Rate for Payer: BCBS Traditional |
$30.00
|
| Rate for Payer: CASH_PRICE |
$24.00
|
| Rate for Payer: CIGNA Commercial |
$28.50
|
| Rate for Payer: CIGNA Medicare |
$27.00
|
| Rate for Payer: HUMANA Commercial |
$27.00
|
| Rate for Payer: MEDICAID Medicaid |
$27.60
|
| Rate for Payer: MEDICARE Medicare |
$21.00
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$28.50
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$29.10
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$28.50
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$28.50
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$25.50
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$24.00
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$24.00
|
|
|
COMFORT FORM WRIST RT XLG
|
Facility
IP
|
$30.00
|
|
| Hospital Charge Code |
20221105
|
|
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 CLOSED PLAN NETWORK |
$28.50
|
| Rate for Payer: BCBS Healthlink |
$27.00
|
| Rate for Payer: BCBS HMK CHIP |
$27.00
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$27.00
|
| Rate for Payer: BCBS POS |
$28.50
|
| Rate for Payer: BCBS Traditional |
$30.00
|
| Rate for Payer: CASH_PRICE |
$24.00
|
| Rate for Payer: CIGNA Commercial |
$28.50
|
| Rate for Payer: CIGNA Medicare |
$27.00
|
| Rate for Payer: HUMANA Commercial |
$27.00
|
| Rate for Payer: MEDICAID Medicaid |
$27.60
|
| Rate for Payer: MEDICARE Medicare |
$21.00
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$28.50
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$29.10
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$28.50
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$28.50
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$25.50
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$24.00
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$24.00
|
|
|
COMM SVCS BY RHC/FQHC 5 MIN
|
Facility
OP
|
$27.00
|
|
|
Service Code
|
CPT G0071
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
521
|
| 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 CLOSED PLAN NETWORK |
$25.65
|
| Rate for Payer: BCBS Healthlink |
$24.30
|
| Rate for Payer: BCBS HMK CHIP |
$24.30
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$24.30
|
| Rate for Payer: BCBS POS |
$25.65
|
| Rate for Payer: BCBS Traditional |
$27.00
|
| Rate for Payer: CASH_PRICE |
$21.60
|
| Rate for Payer: CIGNA Commercial |
$25.65
|
| Rate for Payer: CIGNA Medicare |
$24.30
|
| Rate for Payer: HUMANA Commercial |
$24.30
|
| Rate for Payer: MEDICAID Medicaid |
$24.84
|
| Rate for Payer: MEDICARE Medicare |
$18.90
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$25.65
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$26.19
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$25.65
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$25.65
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$22.95
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$21.60
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$21.60
|
|
|
COMM SVCS BY RHC/FQHC 5 MIN
|
Facility
IP
|
$27.00
|
|
|
Service Code
|
CPT G0071
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$18.90 |
| Max. Negotiated Rate |
$27.00 |
| Rate for Payer: BCBS HMK CHIP |
$24.30
|
| Rate for Payer: AETNA Commercial |
$25.65
|
| Rate for Payer: AETNA Medicare |
$24.30
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$25.65
|
| Rate for Payer: BCBS Healthlink |
$24.30
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$24.30
|
| Rate for Payer: BCBS POS |
$25.65
|
| Rate for Payer: BCBS Traditional |
$27.00
|
| Rate for Payer: CASH_PRICE |
$21.60
|
| Rate for Payer: CIGNA Commercial |
$25.65
|
| Rate for Payer: CIGNA Medicare |
$24.30
|
| Rate for Payer: HUMANA Commercial |
$24.30
|
| Rate for Payer: MEDICAID Medicaid |
$24.84
|
| Rate for Payer: MEDICARE Medicare |
$18.90
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$25.65
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$26.19
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$25.65
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$25.65
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$22.95
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$21.60
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$21.60
|
|
|
COMPLEMENT C1Q (016824)
|
Facility
OP
|
$47.00
|
|
|
Service Code
|
CPT 86160
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$32.90 |
| Max. Negotiated Rate |
$47.00 |
| Rate for Payer: AETNA Commercial |
$44.65
|
| Rate for Payer: AETNA Medicare |
$42.30
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$44.65
|
| Rate for Payer: BCBS Healthlink |
$42.30
|
| Rate for Payer: BCBS HMK CHIP |
$42.30
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$42.30
|
| Rate for Payer: BCBS POS |
$44.65
|
| Rate for Payer: BCBS Traditional |
$47.00
|
| Rate for Payer: CASH_PRICE |
$37.60
|
| Rate for Payer: CIGNA Commercial |
$44.65
|
| Rate for Payer: CIGNA Medicare |
$42.30
|
| Rate for Payer: HUMANA Commercial |
$42.30
|
| Rate for Payer: MEDICAID Medicaid |
$43.24
|
| Rate for Payer: MEDICARE Medicare |
$32.90
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$44.65
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$45.59
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$44.65
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$44.65
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$39.95
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$37.60
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$37.60
|
|
|
COMPLEMENT C1Q (016824)
|
Facility
IP
|
$47.00
|
|
|
Service Code
|
CPT 86160
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$32.90 |
| Max. Negotiated Rate |
$47.00 |
| Rate for Payer: AETNA Commercial |
$44.65
|
| Rate for Payer: AETNA Medicare |
$42.30
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$44.65
|
| Rate for Payer: BCBS Healthlink |
$42.30
|
| Rate for Payer: BCBS HMK CHIP |
$42.30
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$42.30
|
| Rate for Payer: BCBS POS |
$44.65
|
| Rate for Payer: BCBS Traditional |
$47.00
|
| Rate for Payer: CASH_PRICE |
$37.60
|
| Rate for Payer: CIGNA Commercial |
$44.65
|
| Rate for Payer: CIGNA Medicare |
$42.30
|
| Rate for Payer: HUMANA Commercial |
$42.30
|
| Rate for Payer: MEDICAID Medicaid |
$43.24
|
| Rate for Payer: MEDICARE Medicare |
$32.90
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$44.65
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$45.59
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$44.65
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$44.65
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$39.95
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$37.60
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$37.60
|
|
|
COMPLEMENT C3 (006452)
|
Facility
OP
|
$16.00
|
|
|
Service Code
|
CPT 86160
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
300
|
| 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 CLOSED PLAN NETWORK |
$15.20
|
| Rate for Payer: BCBS Healthlink |
$14.40
|
| Rate for Payer: BCBS HMK CHIP |
$14.40
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$14.40
|
| Rate for Payer: BCBS POS |
$15.20
|
| Rate for Payer: BCBS Traditional |
$16.00
|
| Rate for Payer: CASH_PRICE |
$12.80
|
| Rate for Payer: CIGNA Commercial |
$15.20
|
| Rate for Payer: CIGNA Medicare |
$14.40
|
| Rate for Payer: HUMANA Commercial |
$14.40
|
| Rate for Payer: MEDICAID Medicaid |
$14.72
|
| Rate for Payer: MEDICARE Medicare |
$11.20
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$15.20
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$15.52
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$15.20
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$15.20
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$13.60
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$12.80
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$12.80
|
|
|
COMPLEMENT C3 (006452)
|
Facility
IP
|
$16.00
|
|
|
Service Code
|
CPT 86160
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$11.20 |
| Max. Negotiated Rate |
$16.00 |
| Rate for Payer: BCBS HMK CHIP |
$14.40
|
| Rate for Payer: AETNA Commercial |
$15.20
|
| Rate for Payer: AETNA Medicare |
$14.40
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$15.20
|
| Rate for Payer: BCBS Healthlink |
$14.40
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$14.40
|
| Rate for Payer: BCBS POS |
$15.20
|
| Rate for Payer: BCBS Traditional |
$16.00
|
| Rate for Payer: CASH_PRICE |
$12.80
|
| Rate for Payer: CIGNA Commercial |
$15.20
|
| Rate for Payer: CIGNA Medicare |
$14.40
|
| Rate for Payer: HUMANA Commercial |
$14.40
|
| Rate for Payer: MEDICAID Medicaid |
$14.72
|
| Rate for Payer: MEDICARE Medicare |
$11.20
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$15.20
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$15.52
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$15.20
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$15.20
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$13.60
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$12.80
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$12.80
|
|
|
COMPLEMENT C4 (001834)
|
Facility
OP
|
$16.00
|
|
|
Service Code
|
CPT 86160
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
300
|
| 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 CLOSED PLAN NETWORK |
$15.20
|
| Rate for Payer: BCBS Healthlink |
$14.40
|
| Rate for Payer: BCBS HMK CHIP |
$14.40
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$14.40
|
| Rate for Payer: BCBS POS |
$15.20
|
| Rate for Payer: BCBS Traditional |
$16.00
|
| Rate for Payer: CASH_PRICE |
$12.80
|
| Rate for Payer: CIGNA Commercial |
$15.20
|
| Rate for Payer: CIGNA Medicare |
$14.40
|
| Rate for Payer: HUMANA Commercial |
$14.40
|
| Rate for Payer: MEDICAID Medicaid |
$14.72
|
| Rate for Payer: MEDICARE Medicare |
$11.20
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$15.20
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$15.52
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$15.20
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$15.20
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$13.60
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$12.80
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$12.80
|
|
|
COMPLEMENT C4 (001834)
|
Facility
IP
|
$16.00
|
|
|
Service Code
|
CPT 86160
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
300
|
| 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 CLOSED PLAN NETWORK |
$15.20
|
| Rate for Payer: BCBS Healthlink |
$14.40
|
| Rate for Payer: BCBS HMK CHIP |
$14.40
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$14.40
|
| Rate for Payer: BCBS POS |
$15.20
|
| Rate for Payer: BCBS Traditional |
$16.00
|
| Rate for Payer: CASH_PRICE |
$12.80
|
| Rate for Payer: CIGNA Commercial |
$15.20
|
| Rate for Payer: CIGNA Medicare |
$14.40
|
| Rate for Payer: HUMANA Commercial |
$14.40
|
| Rate for Payer: MEDICAID Medicaid |
$14.72
|
| Rate for Payer: MEDICARE Medicare |
$11.20
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$15.20
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$15.52
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$15.20
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$15.20
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$13.60
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$12.80
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$12.80
|
|
