|
KING AIRWAY SIZE 3
|
Facility
|
IP
|
$167.00
|
|
| Hospital Charge Code |
80040150
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$116.90 |
| Max. Negotiated Rate |
$167.00 |
| Rate for Payer: Aetna Commercial |
$158.65
|
| Rate for Payer: Aetna Medicare |
$150.30
|
| Rate for Payer: BCBS MT CHIP |
$150.30
|
| Rate for Payer: BCBS MT Closed Plan Network |
$158.65
|
| Rate for Payer: BCBS MT HealthLink |
$150.30
|
| Rate for Payer: BCBS MT Medicare |
$150.30
|
| Rate for Payer: BCBS MT POS |
$158.65
|
| Rate for Payer: BCBS MT Traditional |
$167.00
|
| Rate for Payer: Cash Price |
$150.30
|
| Rate for Payer: Cigna Commercial |
$158.65
|
| Rate for Payer: Cigna Medicare |
$150.30
|
| Rate for Payer: Medicaid All Medicaid |
$153.64
|
| Rate for Payer: Medicare All Medicare |
$116.90
|
| Rate for Payer: Monida Allegiance |
$158.65
|
| Rate for Payer: Monida First Choice Health |
$161.99
|
| Rate for Payer: Monida Montana Health Co-op |
$158.65
|
| Rate for Payer: Monida PacificSource |
$158.65
|
|
|
KIT COLLECTION
|
Facility
|
OP
|
$26.00
|
|
|
Service Code
|
HCPCS 99000
|
| Hospital Charge Code |
4099002
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$18.20 |
| Max. Negotiated Rate |
$26.00 |
| Rate for Payer: Aetna Commercial |
$24.70
|
| Rate for Payer: Aetna Medicare |
$23.40
|
| Rate for Payer: BCBS MT CHIP |
$23.40
|
| Rate for Payer: BCBS MT Closed Plan Network |
$24.70
|
| Rate for Payer: BCBS MT HealthLink |
$23.40
|
| Rate for Payer: BCBS MT Medicare |
$23.40
|
| Rate for Payer: BCBS MT POS |
$24.70
|
| Rate for Payer: BCBS MT Traditional |
$26.00
|
| Rate for Payer: Cash Price |
$23.40
|
| Rate for Payer: Cigna Commercial |
$24.70
|
| Rate for Payer: Cigna Medicare |
$23.40
|
| Rate for Payer: Medicaid All Medicaid |
$23.92
|
| Rate for Payer: Medicare All Medicare |
$18.20
|
| Rate for Payer: Monida Allegiance |
$24.70
|
| Rate for Payer: Monida First Choice Health |
$25.22
|
| Rate for Payer: Monida Montana Health Co-op |
$24.70
|
| Rate for Payer: Monida PacificSource |
$24.70
|
|
|
KIT COLLECTION
|
Facility
|
IP
|
$26.00
|
|
|
Service Code
|
HCPCS 99000
|
| Hospital Charge Code |
4099002
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$18.20 |
| Max. Negotiated Rate |
$26.00 |
| Rate for Payer: Aetna Commercial |
$24.70
|
| Rate for Payer: Aetna Medicare |
$23.40
|
| Rate for Payer: BCBS MT CHIP |
$23.40
|
| Rate for Payer: BCBS MT Closed Plan Network |
$24.70
|
| Rate for Payer: BCBS MT HealthLink |
$23.40
|
| Rate for Payer: BCBS MT Medicare |
$23.40
|
| Rate for Payer: BCBS MT POS |
$24.70
|
| Rate for Payer: BCBS MT Traditional |
$26.00
|
| Rate for Payer: Cash Price |
$23.40
|
| Rate for Payer: Cigna Commercial |
$24.70
|
| Rate for Payer: Cigna Medicare |
$23.40
|
| Rate for Payer: Medicaid All Medicaid |
$23.92
|
| Rate for Payer: Medicare All Medicare |
$18.20
|
| Rate for Payer: Monida Allegiance |
$24.70
|
| Rate for Payer: Monida First Choice Health |
$25.22
|
| Rate for Payer: Monida Montana Health Co-op |
$24.70
|
| Rate for Payer: Monida PacificSource |
$24.70
|
|
|
KNEE BRACE HINGED
|
Facility
|
IP
|
$64.00
|
|
|
Service Code
|
HCPCS L1833
|
| Hospital Charge Code |
8001833
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$44.80 |
| Max. Negotiated Rate |
$64.00 |
| Rate for Payer: Aetna Commercial |
$60.80
|
| Rate for Payer: Aetna Medicare |
$57.60
|
| Rate for Payer: BCBS MT CHIP |
$57.60
|
| Rate for Payer: BCBS MT Closed Plan Network |
$60.80
|
| Rate for Payer: BCBS MT HealthLink |
$57.60
|
| Rate for Payer: BCBS MT Medicare |
$57.60
|
| Rate for Payer: BCBS MT POS |
$60.80
|
| Rate for Payer: BCBS MT Traditional |
$64.00
|
| Rate for Payer: Cash Price |
$57.60
|
| Rate for Payer: Cigna Commercial |
$60.80
|
| Rate for Payer: Cigna Medicare |
$57.60
|
| Rate for Payer: Medicaid All Medicaid |
$58.88
|
| Rate for Payer: Medicare All Medicare |
$44.80
|
| Rate for Payer: Monida Allegiance |
$60.80
|
| Rate for Payer: Monida First Choice Health |
$62.08
|
| Rate for Payer: Monida Montana Health Co-op |
$60.80
|
| Rate for Payer: Monida PacificSource |
$60.80
|
|
|
KNEE BRACE HINGED
|
Facility
|
OP
|
$64.00
|
|
|
Service Code
|
HCPCS L1833
|
| Hospital Charge Code |
8001833
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$44.80 |
| Max. Negotiated Rate |
$64.00 |
| Rate for Payer: Aetna Commercial |
$60.80
|
| Rate for Payer: Aetna Medicare |
$57.60
|
| Rate for Payer: BCBS MT CHIP |
$57.60
|
| Rate for Payer: BCBS MT Closed Plan Network |
$60.80
|
| Rate for Payer: BCBS MT HealthLink |
$57.60
|
| Rate for Payer: BCBS MT Medicare |
$57.60
|
| Rate for Payer: BCBS MT POS |
$60.80
|
| Rate for Payer: BCBS MT Traditional |
$64.00
|
| Rate for Payer: Cash Price |
$57.60
|
| Rate for Payer: Cigna Commercial |
$60.80
|
| Rate for Payer: Cigna Medicare |
$57.60
|
| Rate for Payer: Medicaid All Medicaid |
$58.88
|
| Rate for Payer: Medicare All Medicare |
$44.80
|
| Rate for Payer: Monida Allegiance |
$60.80
|
| Rate for Payer: Monida First Choice Health |
$62.08
|
| Rate for Payer: Monida Montana Health Co-op |
$60.80
|
| Rate for Payer: Monida PacificSource |
$60.80
|
|
|
KNEE IMMOBILIZER
|
Facility
|
OP
|
$184.00
|
|
|
Service Code
|
HCPCS L1830
|
| Hospital Charge Code |
8001830
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$128.80 |
| Max. Negotiated Rate |
$184.00 |
| Rate for Payer: Aetna Commercial |
$174.80
|
| Rate for Payer: Aetna Medicare |
$165.60
|
| Rate for Payer: BCBS MT CHIP |
$165.60
|
| Rate for Payer: BCBS MT Closed Plan Network |
$174.80
|
| Rate for Payer: BCBS MT HealthLink |
$165.60
|
| Rate for Payer: BCBS MT Medicare |
$165.60
|
| Rate for Payer: BCBS MT POS |
$174.80
|
| Rate for Payer: BCBS MT Traditional |
$184.00
|
| Rate for Payer: Cash Price |
$165.60
|
| Rate for Payer: Cigna Commercial |
$174.80
|
| Rate for Payer: Cigna Medicare |
$165.60
|
| Rate for Payer: Medicaid All Medicaid |
$169.28
|
| Rate for Payer: Medicare All Medicare |
$128.80
|
| Rate for Payer: Monida Allegiance |
$174.80
|
| Rate for Payer: Monida First Choice Health |
$178.48
|
| Rate for Payer: Monida Montana Health Co-op |
$174.80
|
| Rate for Payer: Monida PacificSource |
$174.80
|
|
|
KNEE IMMOBILIZER
|
Facility
|
IP
|
$184.00
|
|
|
Service Code
|
HCPCS L1830
|
| Hospital Charge Code |
8001830
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$128.80 |
| Max. Negotiated Rate |
$184.00 |
| Rate for Payer: Aetna Commercial |
$174.80
|
| Rate for Payer: Aetna Medicare |
$165.60
|
| Rate for Payer: BCBS MT CHIP |
$165.60
|
| Rate for Payer: BCBS MT Closed Plan Network |
$174.80
|
| Rate for Payer: BCBS MT HealthLink |
$165.60
|
| Rate for Payer: BCBS MT Medicare |
$165.60
|
| Rate for Payer: BCBS MT POS |
$174.80
|
| Rate for Payer: BCBS MT Traditional |
$184.00
|
| Rate for Payer: Cash Price |
$165.60
|
| Rate for Payer: Cigna Commercial |
$174.80
|
| Rate for Payer: Cigna Medicare |
$165.60
|
| Rate for Payer: Medicaid All Medicaid |
$169.28
|
| Rate for Payer: Medicare All Medicare |
$128.80
|
| Rate for Payer: Monida Allegiance |
$174.80
|
| Rate for Payer: Monida First Choice Health |
$178.48
|
| Rate for Payer: Monida Montana Health Co-op |
$174.80
|
| Rate for Payer: Monida PacificSource |
$174.80
|
|
|
KNEE SLEEVE LG SHORT
|
Facility
|
IP
|
$30.00
|
|
| Hospital Charge Code |
2893370
|
|
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
|
|
|
KNEE SLEEVE LG SHORT
|
Facility
|
OP
|
$30.00
|
|
| Hospital Charge Code |
2893370
|
|
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
|
|
|
KNEE SLEEVE MED
|
Facility
|
IP
|
$30.00
|
|
| Hospital Charge Code |
2893369
|
|
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
|
|
|
KNEE SLEEVE MED
|
Facility
|
OP
|
$30.00
|
|
| Hospital Charge Code |
2893369
|
|
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
|
|
|
KNEE SLEEVE SM
|
Facility
|
OP
|
$37.00
|
|
| Hospital Charge Code |
2820014
|
|
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 MT CHIP |
$33.30
|
| Rate for Payer: BCBS MT Closed Plan Network |
$35.15
|
| Rate for Payer: BCBS MT HealthLink |
$33.30
|
| Rate for Payer: BCBS MT Medicare |
$33.30
|
| Rate for Payer: BCBS MT POS |
$35.15
|
| Rate for Payer: BCBS MT Traditional |
$37.00
|
| Rate for Payer: Cash Price |
$33.30
|
| Rate for Payer: Cigna Commercial |
$35.15
|
| Rate for Payer: Cigna Medicare |
$33.30
|
| Rate for Payer: Medicaid All Medicaid |
$34.04
|
| Rate for Payer: Medicare All Medicare |
$25.90
|
| Rate for Payer: Monida Allegiance |
$35.15
|
| Rate for Payer: Monida First Choice Health |
$35.89
|
| Rate for Payer: Monida Montana Health Co-op |
$35.15
|
| Rate for Payer: Monida PacificSource |
$35.15
|
|
|
KNEE SLEEVE SM
|
Facility
|
IP
|
$37.00
|
|
| Hospital Charge Code |
2820014
|
|
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 MT CHIP |
$33.30
|
| Rate for Payer: BCBS MT Closed Plan Network |
$35.15
|
| Rate for Payer: BCBS MT HealthLink |
$33.30
|
| Rate for Payer: BCBS MT Medicare |
$33.30
|
| Rate for Payer: BCBS MT POS |
$35.15
|
| Rate for Payer: BCBS MT Traditional |
$37.00
|
| Rate for Payer: Cash Price |
$33.30
|
| Rate for Payer: Cigna Commercial |
$35.15
|
| Rate for Payer: Cigna Medicare |
$33.30
|
| Rate for Payer: Medicaid All Medicaid |
$34.04
|
| Rate for Payer: Medicare All Medicare |
$25.90
|
| Rate for Payer: Monida Allegiance |
$35.15
|
| Rate for Payer: Monida First Choice Health |
$35.89
|
| Rate for Payer: Monida Montana Health Co-op |
$35.15
|
| Rate for Payer: Monida PacificSource |
$35.15
|
|
|
KNEE SLEEVE XLG
|
Facility
|
OP
|
$26.00
|
|
| Hospital Charge Code |
2893371
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$18.20 |
| Max. Negotiated Rate |
$26.00 |
| Rate for Payer: Aetna Commercial |
$24.70
|
| Rate for Payer: Aetna Medicare |
$23.40
|
| Rate for Payer: BCBS MT CHIP |
$23.40
|
| Rate for Payer: BCBS MT Closed Plan Network |
$24.70
|
| Rate for Payer: BCBS MT HealthLink |
$23.40
|
| Rate for Payer: BCBS MT Medicare |
$23.40
|
| Rate for Payer: BCBS MT POS |
$24.70
|
| Rate for Payer: BCBS MT Traditional |
$26.00
|
| Rate for Payer: Cash Price |
$23.40
|
| Rate for Payer: Cigna Commercial |
$24.70
|
| Rate for Payer: Cigna Medicare |
$23.40
|
| Rate for Payer: Medicaid All Medicaid |
$23.92
|
| Rate for Payer: Medicare All Medicare |
$18.20
|
| Rate for Payer: Monida Allegiance |
$24.70
|
| Rate for Payer: Monida First Choice Health |
$25.22
|
| Rate for Payer: Monida Montana Health Co-op |
$24.70
|
| Rate for Payer: Monida PacificSource |
$24.70
|
|
|
KNEE SLEEVE XLG
|
Facility
|
IP
|
$26.00
|
|
| Hospital Charge Code |
2893371
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$18.20 |
| Max. Negotiated Rate |
$26.00 |
| Rate for Payer: Aetna Commercial |
$24.70
|
| Rate for Payer: Aetna Medicare |
$23.40
|
| Rate for Payer: BCBS MT CHIP |
$23.40
|
| Rate for Payer: BCBS MT Closed Plan Network |
$24.70
|
| Rate for Payer: BCBS MT HealthLink |
$23.40
|
| Rate for Payer: BCBS MT Medicare |
$23.40
|
| Rate for Payer: BCBS MT POS |
$24.70
|
| Rate for Payer: BCBS MT Traditional |
$26.00
|
| Rate for Payer: Cash Price |
$23.40
|
| Rate for Payer: Cigna Commercial |
$24.70
|
| Rate for Payer: Cigna Medicare |
$23.40
|
| Rate for Payer: Medicaid All Medicaid |
$23.92
|
| Rate for Payer: Medicare All Medicare |
$18.20
|
| Rate for Payer: Monida Allegiance |
$24.70
|
| Rate for Payer: Monida First Choice Health |
$25.22
|
| Rate for Payer: Monida Montana Health Co-op |
$24.70
|
| Rate for Payer: Monida PacificSource |
$24.70
|
|
|
KNEE SPLINT 18 - 20'' UNIVERSA
|
Facility
|
IP
|
$64.00
|
|
| Hospital Charge Code |
2820013
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$44.80 |
| Max. Negotiated Rate |
$64.00 |
| Rate for Payer: Aetna Commercial |
$60.80
|
| Rate for Payer: Aetna Medicare |
$57.60
|
| Rate for Payer: BCBS MT CHIP |
$57.60
|
| Rate for Payer: BCBS MT Closed Plan Network |
$60.80
|
| Rate for Payer: BCBS MT HealthLink |
$57.60
|
| Rate for Payer: BCBS MT Medicare |
$57.60
|
| Rate for Payer: BCBS MT POS |
$60.80
|
| Rate for Payer: BCBS MT Traditional |
$64.00
|
| Rate for Payer: Cash Price |
$57.60
|
| Rate for Payer: Cigna Commercial |
$60.80
|
| Rate for Payer: Cigna Medicare |
$57.60
|
| Rate for Payer: Medicaid All Medicaid |
$58.88
|
| Rate for Payer: Medicare All Medicare |
$44.80
|
| Rate for Payer: Monida Allegiance |
$60.80
|
| Rate for Payer: Monida First Choice Health |
$62.08
|
| Rate for Payer: Monida Montana Health Co-op |
$60.80
|
| Rate for Payer: Monida PacificSource |
$60.80
|
|
|
KNEE SPLINT 18 - 20'' UNIVERSA
|
Facility
|
OP
|
$64.00
|
|
| Hospital Charge Code |
2820013
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$44.80 |
| Max. Negotiated Rate |
$64.00 |
| Rate for Payer: Aetna Commercial |
$60.80
|
| Rate for Payer: Aetna Medicare |
$57.60
|
| Rate for Payer: BCBS MT CHIP |
$57.60
|
| Rate for Payer: BCBS MT Closed Plan Network |
$60.80
|
| Rate for Payer: BCBS MT HealthLink |
$57.60
|
| Rate for Payer: BCBS MT Medicare |
$57.60
|
| Rate for Payer: BCBS MT POS |
$60.80
|
| Rate for Payer: BCBS MT Traditional |
$64.00
|
| Rate for Payer: Cash Price |
$57.60
|
| Rate for Payer: Cigna Commercial |
$60.80
|
| Rate for Payer: Cigna Medicare |
$57.60
|
| Rate for Payer: Medicaid All Medicaid |
$58.88
|
| Rate for Payer: Medicare All Medicare |
$44.80
|
| Rate for Payer: Monida Allegiance |
$60.80
|
| Rate for Payer: Monida First Choice Health |
$62.08
|
| Rate for Payer: Monida Montana Health Co-op |
$60.80
|
| Rate for Payer: Monida PacificSource |
$60.80
|
|
|
KNEE SPLINT 20" XL
|
Facility
|
IP
|
$51.00
|
|
| Hospital Charge Code |
2893362
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$35.70 |
| Max. Negotiated Rate |
$51.00 |
| Rate for Payer: Aetna Commercial |
$48.45
|
| Rate for Payer: Aetna Medicare |
$45.90
|
| Rate for Payer: BCBS MT CHIP |
$45.90
|
| Rate for Payer: BCBS MT Closed Plan Network |
$48.45
|
| Rate for Payer: BCBS MT HealthLink |
$45.90
|
| Rate for Payer: BCBS MT Medicare |
$45.90
|
| Rate for Payer: BCBS MT POS |
$48.45
|
| Rate for Payer: BCBS MT Traditional |
$51.00
|
| Rate for Payer: Cash Price |
$45.90
|
| Rate for Payer: Cigna Commercial |
$48.45
|
| Rate for Payer: Cigna Medicare |
$45.90
|
| Rate for Payer: Medicaid All Medicaid |
$46.92
|
| Rate for Payer: Medicare All Medicare |
$35.70
|
| Rate for Payer: Monida Allegiance |
$48.45
|
| Rate for Payer: Monida First Choice Health |
$49.47
|
| Rate for Payer: Monida Montana Health Co-op |
$48.45
|
| Rate for Payer: Monida PacificSource |
$48.45
|
|
|
KNEE SPLINT 20" XL
|
Facility
|
OP
|
$51.00
|
|
| Hospital Charge Code |
2893362
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$35.70 |
| Max. Negotiated Rate |
$51.00 |
| Rate for Payer: Aetna Commercial |
$48.45
|
| Rate for Payer: Aetna Medicare |
$45.90
|
| Rate for Payer: BCBS MT CHIP |
$45.90
|
| Rate for Payer: BCBS MT Closed Plan Network |
$48.45
|
| Rate for Payer: BCBS MT HealthLink |
$45.90
|
| Rate for Payer: BCBS MT Medicare |
$45.90
|
| Rate for Payer: BCBS MT POS |
$48.45
|
| Rate for Payer: BCBS MT Traditional |
$51.00
|
| Rate for Payer: Cash Price |
$45.90
|
| Rate for Payer: Cigna Commercial |
$48.45
|
| Rate for Payer: Cigna Medicare |
$45.90
|
| Rate for Payer: Medicaid All Medicaid |
$46.92
|
| Rate for Payer: Medicare All Medicare |
$35.70
|
| Rate for Payer: Monida Allegiance |
$48.45
|
| Rate for Payer: Monida First Choice Health |
$49.47
|
| Rate for Payer: Monida Montana Health Co-op |
$48.45
|
| Rate for Payer: Monida PacificSource |
$48.45
|
|
|
KNEE SPLINT 20'' XXL
|
Facility
|
OP
|
$51.00
|
|
| Hospital Charge Code |
2893363
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$35.70 |
| Max. Negotiated Rate |
$51.00 |
| Rate for Payer: Aetna Commercial |
$48.45
|
| Rate for Payer: Aetna Medicare |
$45.90
|
| Rate for Payer: BCBS MT CHIP |
$45.90
|
| Rate for Payer: BCBS MT Closed Plan Network |
$48.45
|
| Rate for Payer: BCBS MT HealthLink |
$45.90
|
| Rate for Payer: BCBS MT Medicare |
$45.90
|
| Rate for Payer: BCBS MT POS |
$48.45
|
| Rate for Payer: BCBS MT Traditional |
$51.00
|
| Rate for Payer: Cash Price |
$45.90
|
| Rate for Payer: Cigna Commercial |
$48.45
|
| Rate for Payer: Cigna Medicare |
$45.90
|
| Rate for Payer: Medicaid All Medicaid |
$46.92
|
| Rate for Payer: Medicare All Medicare |
$35.70
|
| Rate for Payer: Monida Allegiance |
$48.45
|
| Rate for Payer: Monida First Choice Health |
$49.47
|
| Rate for Payer: Monida Montana Health Co-op |
$48.45
|
| Rate for Payer: Monida PacificSource |
$48.45
|
|
|
KNEE SPLINT 20'' XXL
|
Facility
|
IP
|
$51.00
|
|
| Hospital Charge Code |
2893363
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$35.70 |
| Max. Negotiated Rate |
$51.00 |
| Rate for Payer: Aetna Commercial |
$48.45
|
| Rate for Payer: Aetna Medicare |
$45.90
|
| Rate for Payer: BCBS MT CHIP |
$45.90
|
| Rate for Payer: BCBS MT Closed Plan Network |
$48.45
|
| Rate for Payer: BCBS MT HealthLink |
$45.90
|
| Rate for Payer: BCBS MT Medicare |
$45.90
|
| Rate for Payer: BCBS MT POS |
$48.45
|
| Rate for Payer: BCBS MT Traditional |
$51.00
|
| Rate for Payer: Cash Price |
$45.90
|
| Rate for Payer: Cigna Commercial |
$48.45
|
| Rate for Payer: Cigna Medicare |
$45.90
|
| Rate for Payer: Medicaid All Medicaid |
$46.92
|
| Rate for Payer: Medicare All Medicare |
$35.70
|
| Rate for Payer: Monida Allegiance |
$48.45
|
| Rate for Payer: Monida First Choice Health |
$49.47
|
| Rate for Payer: Monida Montana Health Co-op |
$48.45
|
| Rate for Payer: Monida PacificSource |
$48.45
|
|
|
KNEE SPLINT 22" LG
|
Facility
|
OP
|
$59.00
|
|
| Hospital Charge Code |
2893365
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$41.30 |
| Max. Negotiated Rate |
$59.00 |
| Rate for Payer: Aetna Commercial |
$56.05
|
| Rate for Payer: Aetna Medicare |
$53.10
|
| Rate for Payer: BCBS MT CHIP |
$53.10
|
| Rate for Payer: BCBS MT Closed Plan Network |
$56.05
|
| Rate for Payer: BCBS MT HealthLink |
$53.10
|
| Rate for Payer: BCBS MT Medicare |
$53.10
|
| Rate for Payer: BCBS MT POS |
$56.05
|
| Rate for Payer: BCBS MT Traditional |
$59.00
|
| Rate for Payer: Cash Price |
$53.10
|
| Rate for Payer: Cigna Commercial |
$56.05
|
| Rate for Payer: Cigna Medicare |
$53.10
|
| Rate for Payer: Medicaid All Medicaid |
$54.28
|
| Rate for Payer: Medicare All Medicare |
$41.30
|
| Rate for Payer: Monida Allegiance |
$56.05
|
| Rate for Payer: Monida First Choice Health |
$57.23
|
| Rate for Payer: Monida Montana Health Co-op |
$56.05
|
| Rate for Payer: Monida PacificSource |
$56.05
|
|
|
KNEE SPLINT 22" LG
|
Facility
|
IP
|
$59.00
|
|
| Hospital Charge Code |
2893365
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$41.30 |
| Max. Negotiated Rate |
$59.00 |
| Rate for Payer: Aetna Commercial |
$56.05
|
| Rate for Payer: Aetna Medicare |
$53.10
|
| Rate for Payer: BCBS MT CHIP |
$53.10
|
| Rate for Payer: BCBS MT Closed Plan Network |
$56.05
|
| Rate for Payer: BCBS MT HealthLink |
$53.10
|
| Rate for Payer: BCBS MT Medicare |
$53.10
|
| Rate for Payer: BCBS MT POS |
$56.05
|
| Rate for Payer: BCBS MT Traditional |
$59.00
|
| Rate for Payer: Cash Price |
$53.10
|
| Rate for Payer: Cigna Commercial |
$56.05
|
| Rate for Payer: Cigna Medicare |
$53.10
|
| Rate for Payer: Medicaid All Medicaid |
$54.28
|
| Rate for Payer: Medicare All Medicare |
$41.30
|
| Rate for Payer: Monida Allegiance |
$56.05
|
| Rate for Payer: Monida First Choice Health |
$57.23
|
| Rate for Payer: Monida Montana Health Co-op |
$56.05
|
| Rate for Payer: Monida PacificSource |
$56.05
|
|
|
KNEE SPLINT 22" MED
|
Facility
|
IP
|
$59.00
|
|
| Hospital Charge Code |
2893364
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$41.30 |
| Max. Negotiated Rate |
$59.00 |
| Rate for Payer: Aetna Commercial |
$56.05
|
| Rate for Payer: Aetna Medicare |
$53.10
|
| Rate for Payer: BCBS MT CHIP |
$53.10
|
| Rate for Payer: BCBS MT Closed Plan Network |
$56.05
|
| Rate for Payer: BCBS MT HealthLink |
$53.10
|
| Rate for Payer: BCBS MT Medicare |
$53.10
|
| Rate for Payer: BCBS MT POS |
$56.05
|
| Rate for Payer: BCBS MT Traditional |
$59.00
|
| Rate for Payer: Cash Price |
$53.10
|
| Rate for Payer: Cigna Commercial |
$56.05
|
| Rate for Payer: Cigna Medicare |
$53.10
|
| Rate for Payer: Medicaid All Medicaid |
$54.28
|
| Rate for Payer: Medicare All Medicare |
$41.30
|
| Rate for Payer: Monida Allegiance |
$56.05
|
| Rate for Payer: Monida First Choice Health |
$57.23
|
| Rate for Payer: Monida Montana Health Co-op |
$56.05
|
| Rate for Payer: Monida PacificSource |
$56.05
|
|
|
KNEE SPLINT 22" MED
|
Facility
|
OP
|
$59.00
|
|
| Hospital Charge Code |
2893364
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$41.30 |
| Max. Negotiated Rate |
$59.00 |
| Rate for Payer: Aetna Commercial |
$56.05
|
| Rate for Payer: Aetna Medicare |
$53.10
|
| Rate for Payer: BCBS MT CHIP |
$53.10
|
| Rate for Payer: BCBS MT Closed Plan Network |
$56.05
|
| Rate for Payer: BCBS MT HealthLink |
$53.10
|
| Rate for Payer: BCBS MT Medicare |
$53.10
|
| Rate for Payer: BCBS MT POS |
$56.05
|
| Rate for Payer: BCBS MT Traditional |
$59.00
|
| Rate for Payer: Cash Price |
$53.10
|
| Rate for Payer: Cigna Commercial |
$56.05
|
| Rate for Payer: Cigna Medicare |
$53.10
|
| Rate for Payer: Medicaid All Medicaid |
$54.28
|
| Rate for Payer: Medicare All Medicare |
$41.30
|
| Rate for Payer: Monida Allegiance |
$56.05
|
| Rate for Payer: Monida First Choice Health |
$57.23
|
| Rate for Payer: Monida Montana Health Co-op |
$56.05
|
| Rate for Payer: Monida PacificSource |
$56.05
|
|
