Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

ANDROSTENEDIONE

Facility

$120.00

Service Code	CPT 82157
Hospital Charge Code	4088105
Hospital Revenue Code	302
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

ANDROSTENEDIONE

Facility

$120.00

Service Code	CPT 82157
Hospital Charge Code	4088105
Hospital Revenue Code	302
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

ANESTHESIA COLON& EGD 00813

Facility

$833.00

Service Code	CPT 813
Hospital Charge Code	5840008
Hospital Revenue Code	370
Min. Negotiated Rate	$583.10
Max. Negotiated Rate	$833.00
Rate for Payer: Aetna Commercial	$791.35
Rate for Payer: Aetna Medicare	$749.70
Rate for Payer: BCBS MT CHIP	$749.70
Rate for Payer: BCBS MT Closed Plan Network	$791.35
Rate for Payer: BCBS MT HealthLink	$749.70
Rate for Payer: BCBS MT Medicare	$749.70
Rate for Payer: BCBS MT POS	$791.35
Rate for Payer: BCBS MT Traditional	$833.00
Rate for Payer: Cash Price	$749.70
Rate for Payer: Cigna Commercial	$791.35
Rate for Payer: Cigna Medicare	$749.70
Rate for Payer: Medicaid All Medicaid	$766.36
Rate for Payer: Medicare All Medicare	$583.10
Rate for Payer: Monida Allegiance	$791.35
Rate for Payer: Monida First Choice Health	$808.01
Rate for Payer: Monida Montana Health Co-op	$791.35
Rate for Payer: Monida PacificSource	$791.35

ANESTHESIA COLON& EGD 00813

Facility

$833.00

Service Code	CPT 813
Hospital Charge Code	5840008
Hospital Revenue Code	370
Min. Negotiated Rate	$583.10
Max. Negotiated Rate	$833.00
Rate for Payer: Aetna Commercial	$791.35
Rate for Payer: Aetna Medicare	$749.70
Rate for Payer: BCBS MT CHIP	$749.70
Rate for Payer: BCBS MT Closed Plan Network	$791.35
Rate for Payer: BCBS MT HealthLink	$749.70
Rate for Payer: BCBS MT Medicare	$749.70
Rate for Payer: BCBS MT POS	$791.35
Rate for Payer: BCBS MT Traditional	$833.00
Rate for Payer: Cash Price	$749.70
Rate for Payer: Cigna Commercial	$791.35
Rate for Payer: Cigna Medicare	$749.70
Rate for Payer: Medicaid All Medicaid	$766.36
Rate for Payer: Medicare All Medicare	$583.10
Rate for Payer: Monida Allegiance	$791.35
Rate for Payer: Monida First Choice Health	$808.01
Rate for Payer: Monida Montana Health Co-op	$791.35
Rate for Payer: Monida PacificSource	$791.35

ANESTHESIA COLONOSCOPY 00811

Facility

$867.00

Service Code	CPT 811
Hospital Charge Code	5800811
Hospital Revenue Code	370
Min. Negotiated Rate	$606.90
Max. Negotiated Rate	$867.00
Rate for Payer: Aetna Commercial	$823.65
Rate for Payer: Aetna Medicare	$780.30
Rate for Payer: BCBS MT CHIP	$780.30
Rate for Payer: BCBS MT Closed Plan Network	$823.65
Rate for Payer: BCBS MT HealthLink	$780.30
Rate for Payer: BCBS MT Medicare	$780.30
Rate for Payer: BCBS MT POS	$823.65
Rate for Payer: BCBS MT Traditional	$867.00
Rate for Payer: Cash Price	$780.30
Rate for Payer: Cigna Commercial	$823.65
Rate for Payer: Cigna Medicare	$780.30
Rate for Payer: Medicaid All Medicaid	$797.64
Rate for Payer: Medicare All Medicare	$606.90
Rate for Payer: Monida Allegiance	$823.65
Rate for Payer: Monida First Choice Health	$840.99
Rate for Payer: Monida Montana Health Co-op	$823.65
Rate for Payer: Monida PacificSource	$823.65

ANESTHESIA COLONOSCOPY 00811

Facility

$867.00

Service Code	CPT 811
Hospital Charge Code	5800811
Hospital Revenue Code	370
Min. Negotiated Rate	$606.90
Max. Negotiated Rate	$867.00
Rate for Payer: Aetna Commercial	$823.65
Rate for Payer: Aetna Medicare	$780.30
Rate for Payer: BCBS MT CHIP	$780.30
Rate for Payer: BCBS MT Closed Plan Network	$823.65
Rate for Payer: BCBS MT HealthLink	$780.30
Rate for Payer: BCBS MT Medicare	$780.30
Rate for Payer: BCBS MT POS	$823.65
Rate for Payer: BCBS MT Traditional	$867.00
Rate for Payer: Cash Price	$780.30
Rate for Payer: Cigna Commercial	$823.65
Rate for Payer: Cigna Medicare	$780.30
Rate for Payer: Medicaid All Medicaid	$797.64
Rate for Payer: Medicare All Medicare	$606.90
Rate for Payer: Monida Allegiance	$823.65
Rate for Payer: Monida First Choice Health	$840.99
Rate for Payer: Monida Montana Health Co-op	$823.65
Rate for Payer: Monida PacificSource	$823.65

ANESTHESIA COLONOSCOPY 00812

Facility

$827.00

Service Code	CPT 812
Hospital Charge Code	5840005
Hospital Revenue Code	370
Min. Negotiated Rate	$578.90
Max. Negotiated Rate	$827.00
Rate for Payer: Aetna Commercial	$785.65
Rate for Payer: Aetna Medicare	$744.30
Rate for Payer: BCBS MT CHIP	$744.30
Rate for Payer: BCBS MT Closed Plan Network	$785.65
Rate for Payer: BCBS MT HealthLink	$744.30
Rate for Payer: BCBS MT Medicare	$744.30
Rate for Payer: BCBS MT POS	$785.65
Rate for Payer: BCBS MT Traditional	$827.00
Rate for Payer: Cash Price	$744.30
Rate for Payer: Cigna Commercial	$785.65
Rate for Payer: Cigna Medicare	$744.30
Rate for Payer: Medicaid All Medicaid	$760.84
Rate for Payer: Medicare All Medicare	$578.90
Rate for Payer: Monida Allegiance	$785.65
Rate for Payer: Monida First Choice Health	$802.19
Rate for Payer: Monida Montana Health Co-op	$785.65
Rate for Payer: Monida PacificSource	$785.65

ANESTHESIA COLONOSCOPY 00812

Facility

$827.00

Service Code	CPT 812
Hospital Charge Code	5840005
Hospital Revenue Code	370
Min. Negotiated Rate	$578.90
Max. Negotiated Rate	$827.00
Rate for Payer: Aetna Commercial	$785.65
Rate for Payer: Aetna Medicare	$744.30
Rate for Payer: BCBS MT CHIP	$744.30
Rate for Payer: BCBS MT Closed Plan Network	$785.65
Rate for Payer: BCBS MT HealthLink	$744.30
Rate for Payer: BCBS MT Medicare	$744.30
Rate for Payer: BCBS MT POS	$785.65
Rate for Payer: BCBS MT Traditional	$827.00
Rate for Payer: Cash Price	$744.30
Rate for Payer: Cigna Commercial	$785.65
Rate for Payer: Cigna Medicare	$744.30
Rate for Payer: Medicaid All Medicaid	$760.84
Rate for Payer: Medicare All Medicare	$578.90
Rate for Payer: Monida Allegiance	$785.65
Rate for Payer: Monida First Choice Health	$802.19
Rate for Payer: Monida Montana Health Co-op	$785.65
Rate for Payer: Monida PacificSource	$785.65

ANESTHESIA ENDO 00731

Facility

$866.00

Service Code	CPT 731
Hospital Charge Code	5800812
Hospital Revenue Code	370
Min. Negotiated Rate	$606.20
Max. Negotiated Rate	$866.00
Rate for Payer: Aetna Commercial	$822.70
Rate for Payer: Aetna Medicare	$779.40
Rate for Payer: BCBS MT CHIP	$779.40
Rate for Payer: BCBS MT Closed Plan Network	$822.70
Rate for Payer: BCBS MT HealthLink	$779.40
Rate for Payer: BCBS MT Medicare	$779.40
Rate for Payer: BCBS MT POS	$822.70
Rate for Payer: BCBS MT Traditional	$866.00
Rate for Payer: Cash Price	$779.40
Rate for Payer: Cigna Commercial	$822.70
Rate for Payer: Cigna Medicare	$779.40
Rate for Payer: Medicaid All Medicaid	$796.72
Rate for Payer: Medicare All Medicare	$606.20
Rate for Payer: Monida Allegiance	$822.70
Rate for Payer: Monida First Choice Health	$840.02
Rate for Payer: Monida Montana Health Co-op	$822.70
Rate for Payer: Monida PacificSource	$822.70

ANESTHESIA ENDO 00731

Facility

$866.00

Service Code	CPT 731
Hospital Charge Code	5800812
Hospital Revenue Code	370
Min. Negotiated Rate	$606.20
Max. Negotiated Rate	$866.00
Rate for Payer: Aetna Commercial	$822.70
Rate for Payer: Aetna Medicare	$779.40
Rate for Payer: BCBS MT CHIP	$779.40
Rate for Payer: BCBS MT Closed Plan Network	$822.70
Rate for Payer: BCBS MT HealthLink	$779.40
Rate for Payer: BCBS MT Medicare	$779.40
Rate for Payer: BCBS MT POS	$822.70
Rate for Payer: BCBS MT Traditional	$866.00
Rate for Payer: Cash Price	$779.40
Rate for Payer: Cigna Commercial	$822.70
Rate for Payer: Cigna Medicare	$779.40
Rate for Payer: Medicaid All Medicaid	$796.72
Rate for Payer: Medicare All Medicare	$606.20
Rate for Payer: Monida Allegiance	$822.70
Rate for Payer: Monida First Choice Health	$840.02
Rate for Payer: Monida Montana Health Co-op	$822.70
Rate for Payer: Monida PacificSource	$822.70

ANGIOTENSIN CONVERTING ENZYME (010116)

Facility

$20.00

Service Code	CPT 82164
Hospital Charge Code	4082164
Hospital Revenue Code	300
Min. Negotiated Rate	$14.00
Max. Negotiated Rate	$20.00
Rate for Payer: Aetna Commercial	$19.00
Rate for Payer: Aetna Medicare	$18.00
Rate for Payer: BCBS MT CHIP	$18.00
Rate for Payer: BCBS MT Closed Plan Network	$19.00
Rate for Payer: BCBS MT HealthLink	$18.00
Rate for Payer: BCBS MT Medicare	$18.00
Rate for Payer: BCBS MT POS	$19.00
Rate for Payer: BCBS MT Traditional	$20.00
Rate for Payer: Cash Price	$18.00
Rate for Payer: Cigna Commercial	$19.00
Rate for Payer: Cigna Medicare	$18.00
Rate for Payer: Medicaid All Medicaid	$18.40
Rate for Payer: Medicare All Medicare	$14.00
Rate for Payer: Monida Allegiance	$19.00
Rate for Payer: Monida First Choice Health	$19.40
Rate for Payer: Monida Montana Health Co-op	$19.00
Rate for Payer: Monida PacificSource	$19.00

ANGIOTENSIN CONVERTING ENZYME (010116)

Facility

$20.00

Service Code	CPT 82164
Hospital Charge Code	4082164
Hospital Revenue Code	300
Min. Negotiated Rate	$14.00
Max. Negotiated Rate	$20.00
Rate for Payer: Aetna Commercial	$19.00
Rate for Payer: Aetna Medicare	$18.00
Rate for Payer: BCBS MT CHIP	$18.00
Rate for Payer: BCBS MT Closed Plan Network	$19.00
Rate for Payer: BCBS MT HealthLink	$18.00
Rate for Payer: BCBS MT Medicare	$18.00
Rate for Payer: BCBS MT POS	$19.00
Rate for Payer: BCBS MT Traditional	$20.00
Rate for Payer: Cash Price	$18.00
Rate for Payer: Cigna Commercial	$19.00
Rate for Payer: Cigna Medicare	$18.00
Rate for Payer: Medicaid All Medicaid	$18.40
Rate for Payer: Medicare All Medicare	$14.00
Rate for Payer: Monida Allegiance	$19.00
Rate for Payer: Monida First Choice Health	$19.40
Rate for Payer: Monida Montana Health Co-op	$19.00
Rate for Payer: Monida PacificSource	$19.00

ANKLE BRACE

Facility

$336.00

Service Code	HCPCS L1906
Hospital Charge Code	8001906
Hospital Revenue Code	290
Min. Negotiated Rate	$235.20
Max. Negotiated Rate	$336.00
Rate for Payer: Aetna Commercial	$319.20
Rate for Payer: Aetna Medicare	$302.40
Rate for Payer: BCBS MT CHIP	$302.40
Rate for Payer: BCBS MT Closed Plan Network	$319.20
Rate for Payer: BCBS MT HealthLink	$302.40
Rate for Payer: BCBS MT Medicare	$302.40
Rate for Payer: BCBS MT POS	$319.20
Rate for Payer: BCBS MT Traditional	$336.00
Rate for Payer: Cash Price	$302.40
Rate for Payer: Cigna Commercial	$319.20
Rate for Payer: Cigna Medicare	$302.40
Rate for Payer: Medicaid All Medicaid	$309.12
Rate for Payer: Medicare All Medicare	$235.20
Rate for Payer: Monida Allegiance	$319.20
Rate for Payer: Monida First Choice Health	$325.92
Rate for Payer: Monida Montana Health Co-op	$319.20
Rate for Payer: Monida PacificSource	$319.20

ANKLE BRACE

Facility

$336.00

Service Code	HCPCS L1906
Hospital Charge Code	8001906
Hospital Revenue Code	290
Min. Negotiated Rate	$235.20
Max. Negotiated Rate	$336.00
Rate for Payer: Aetna Commercial	$319.20
Rate for Payer: Aetna Medicare	$302.40
Rate for Payer: BCBS MT CHIP	$302.40
Rate for Payer: BCBS MT Closed Plan Network	$319.20
Rate for Payer: BCBS MT HealthLink	$302.40
Rate for Payer: BCBS MT Medicare	$302.40
Rate for Payer: BCBS MT POS	$319.20
Rate for Payer: BCBS MT Traditional	$336.00
Rate for Payer: Cash Price	$302.40
Rate for Payer: Cigna Commercial	$319.20
Rate for Payer: Cigna Medicare	$302.40
Rate for Payer: Medicaid All Medicaid	$309.12
Rate for Payer: Medicare All Medicare	$235.20
Rate for Payer: Monida Allegiance	$319.20
Rate for Payer: Monida First Choice Health	$325.92
Rate for Payer: Monida Montana Health Co-op	$319.20
Rate for Payer: Monida PacificSource	$319.20

ANKLE BRACE AIR GEL 9.0''

Facility

$49.00

Hospital Charge Code	2893172
Hospital Revenue Code	290
Min. Negotiated Rate	$34.30
Max. Negotiated Rate	$49.00
Rate for Payer: Aetna Commercial	$46.55
Rate for Payer: Aetna Medicare	$44.10
Rate for Payer: BCBS MT CHIP	$44.10
Rate for Payer: BCBS MT Closed Plan Network	$46.55
Rate for Payer: BCBS MT HealthLink	$44.10
Rate for Payer: BCBS MT Medicare	$44.10
Rate for Payer: BCBS MT POS	$46.55
Rate for Payer: BCBS MT Traditional	$49.00
Rate for Payer: Cash Price	$44.10
Rate for Payer: Cigna Commercial	$46.55
Rate for Payer: Cigna Medicare	$44.10
Rate for Payer: Medicaid All Medicaid	$45.08
Rate for Payer: Medicare All Medicare	$34.30
Rate for Payer: Monida Allegiance	$46.55
Rate for Payer: Monida First Choice Health	$47.53
Rate for Payer: Monida Montana Health Co-op	$46.55
Rate for Payer: Monida PacificSource	$46.55

ANKLE BRACE AIR GEL 9.0''

Facility

$49.00

Hospital Charge Code	2893172
Hospital Revenue Code	290
Min. Negotiated Rate	$34.30
Max. Negotiated Rate	$49.00
Rate for Payer: Aetna Commercial	$46.55
Rate for Payer: Aetna Medicare	$44.10
Rate for Payer: BCBS MT CHIP	$44.10
Rate for Payer: BCBS MT Closed Plan Network	$46.55
Rate for Payer: BCBS MT HealthLink	$44.10
Rate for Payer: BCBS MT Medicare	$44.10
Rate for Payer: BCBS MT POS	$46.55
Rate for Payer: BCBS MT Traditional	$49.00
Rate for Payer: Cash Price	$44.10
Rate for Payer: Cigna Commercial	$46.55
Rate for Payer: Cigna Medicare	$44.10
Rate for Payer: Medicaid All Medicaid	$45.08
Rate for Payer: Medicare All Medicare	$34.30
Rate for Payer: Monida Allegiance	$46.55
Rate for Payer: Monida First Choice Health	$47.53
Rate for Payer: Monida Montana Health Co-op	$46.55
Rate for Payer: Monida PacificSource	$46.55

ANKLE BRACE AIR GEL SM. 8.5

Facility

$57.00

Hospital Charge Code	2893151
Hospital Revenue Code	270
Min. Negotiated Rate	$39.90
Max. Negotiated Rate	$57.00
Rate for Payer: Aetna Commercial	$54.15
Rate for Payer: Aetna Medicare	$51.30
Rate for Payer: BCBS MT CHIP	$51.30
Rate for Payer: BCBS MT Closed Plan Network	$54.15
Rate for Payer: BCBS MT HealthLink	$51.30
Rate for Payer: BCBS MT Medicare	$51.30
Rate for Payer: BCBS MT POS	$54.15
Rate for Payer: BCBS MT Traditional	$57.00
Rate for Payer: Cash Price	$51.30
Rate for Payer: Cigna Commercial	$54.15
Rate for Payer: Cigna Medicare	$51.30
Rate for Payer: Medicaid All Medicaid	$52.44
Rate for Payer: Medicare All Medicare	$39.90
Rate for Payer: Monida Allegiance	$54.15
Rate for Payer: Monida First Choice Health	$55.29
Rate for Payer: Monida Montana Health Co-op	$54.15
Rate for Payer: Monida PacificSource	$54.15

ANKLE BRACE AIR GEL SM. 8.5

Facility

$57.00

Hospital Charge Code	2893151
Hospital Revenue Code	270
Min. Negotiated Rate	$39.90
Max. Negotiated Rate	$57.00
Rate for Payer: Aetna Commercial	$54.15
Rate for Payer: Aetna Medicare	$51.30
Rate for Payer: BCBS MT CHIP	$51.30
Rate for Payer: BCBS MT Closed Plan Network	$54.15
Rate for Payer: BCBS MT HealthLink	$51.30
Rate for Payer: BCBS MT Medicare	$51.30
Rate for Payer: BCBS MT POS	$54.15
Rate for Payer: BCBS MT Traditional	$57.00
Rate for Payer: Cash Price	$51.30
Rate for Payer: Cigna Commercial	$54.15
Rate for Payer: Cigna Medicare	$51.30
Rate for Payer: Medicaid All Medicaid	$52.44
Rate for Payer: Medicare All Medicare	$39.90
Rate for Payer: Monida Allegiance	$54.15
Rate for Payer: Monida First Choice Health	$55.29
Rate for Payer: Monida Montana Health Co-op	$54.15
Rate for Payer: Monida PacificSource	$54.15

ANKLE-BRACHIAL INDEX ABI

Facility

$422.00

Service Code	CPT 93922
Hospital Charge Code	8093922
Hospital Revenue Code	521
Min. Negotiated Rate	$295.40
Max. Negotiated Rate	$422.00
Rate for Payer: Aetna Commercial	$400.90
Rate for Payer: Aetna Medicare	$379.80
Rate for Payer: BCBS MT CHIP	$379.80
Rate for Payer: BCBS MT Closed Plan Network	$400.90
Rate for Payer: BCBS MT HealthLink	$379.80
Rate for Payer: BCBS MT Medicare	$379.80
Rate for Payer: BCBS MT POS	$400.90
Rate for Payer: BCBS MT Traditional	$422.00
Rate for Payer: Cash Price	$379.80
Rate for Payer: Cigna Commercial	$400.90
Rate for Payer: Cigna Medicare	$379.80
Rate for Payer: Medicaid All Medicaid	$388.24
Rate for Payer: Medicare All Medicare	$295.40
Rate for Payer: Monida Allegiance	$400.90
Rate for Payer: Monida First Choice Health	$409.34
Rate for Payer: Monida Montana Health Co-op	$400.90
Rate for Payer: Monida PacificSource	$400.90

ANKLE-BRACHIAL INDEX ABI

Facility

$422.00

Service Code	CPT 93922
Hospital Charge Code	8093922
Hospital Revenue Code	521
Min. Negotiated Rate	$295.40
Max. Negotiated Rate	$422.00
Rate for Payer: Aetna Commercial	$400.90
Rate for Payer: Aetna Medicare	$379.80
Rate for Payer: BCBS MT CHIP	$379.80
Rate for Payer: BCBS MT Closed Plan Network	$400.90
Rate for Payer: BCBS MT HealthLink	$379.80
Rate for Payer: BCBS MT Medicare	$379.80
Rate for Payer: BCBS MT POS	$400.90
Rate for Payer: BCBS MT Traditional	$422.00
Rate for Payer: Cash Price	$379.80
Rate for Payer: Cigna Commercial	$400.90
Rate for Payer: Cigna Medicare	$379.80
Rate for Payer: Medicaid All Medicaid	$388.24
Rate for Payer: Medicare All Medicare	$295.40
Rate for Payer: Monida Allegiance	$400.90
Rate for Payer: Monida First Choice Health	$409.34
Rate for Payer: Monida Montana Health Co-op	$400.90
Rate for Payer: Monida PacificSource	$400.90

ANKLE SPINT LACE-UP SM

Facility

$44.00

Hospital Charge Code	2820002
Hospital Revenue Code	270
Min. Negotiated Rate	$30.80
Max. Negotiated Rate	$44.00
Rate for Payer: Aetna Commercial	$41.80
Rate for Payer: Aetna Medicare	$39.60
Rate for Payer: BCBS MT CHIP	$39.60
Rate for Payer: BCBS MT Closed Plan Network	$41.80
Rate for Payer: BCBS MT HealthLink	$39.60
Rate for Payer: BCBS MT Medicare	$39.60
Rate for Payer: BCBS MT POS	$41.80
Rate for Payer: BCBS MT Traditional	$44.00
Rate for Payer: Cash Price	$39.60
Rate for Payer: Cigna Commercial	$41.80
Rate for Payer: Cigna Medicare	$39.60
Rate for Payer: Medicaid All Medicaid	$40.48
Rate for Payer: Medicare All Medicare	$30.80
Rate for Payer: Monida Allegiance	$41.80
Rate for Payer: Monida First Choice Health	$42.68
Rate for Payer: Monida Montana Health Co-op	$41.80
Rate for Payer: Monida PacificSource	$41.80

ANKLE SPINT LACE-UP SM

Facility

$44.00

Hospital Charge Code	2820002
Hospital Revenue Code	270
Min. Negotiated Rate	$30.80
Max. Negotiated Rate	$44.00
Rate for Payer: Aetna Commercial	$41.80
Rate for Payer: Aetna Medicare	$39.60
Rate for Payer: BCBS MT CHIP	$39.60
Rate for Payer: BCBS MT Closed Plan Network	$41.80
Rate for Payer: BCBS MT HealthLink	$39.60
Rate for Payer: BCBS MT Medicare	$39.60
Rate for Payer: BCBS MT POS	$41.80
Rate for Payer: BCBS MT Traditional	$44.00
Rate for Payer: Cash Price	$39.60
Rate for Payer: Cigna Commercial	$41.80
Rate for Payer: Cigna Medicare	$39.60
Rate for Payer: Medicaid All Medicaid	$40.48
Rate for Payer: Medicare All Medicare	$30.80
Rate for Payer: Monida Allegiance	$41.80
Rate for Payer: Monida First Choice Health	$42.68
Rate for Payer: Monida Montana Health Co-op	$41.80
Rate for Payer: Monida PacificSource	$41.80

ANKLE SPLINT LACE-UP LG

Facility

$38.00

Service Code	HCPCS E1815
Hospital Charge Code	2893174
Hospital Revenue Code	290
Min. Negotiated Rate	$26.60
Max. Negotiated Rate	$38.00
Rate for Payer: Aetna Commercial	$36.10
Rate for Payer: Aetna Medicare	$34.20
Rate for Payer: BCBS MT CHIP	$34.20
Rate for Payer: BCBS MT Closed Plan Network	$36.10
Rate for Payer: BCBS MT HealthLink	$34.20
Rate for Payer: BCBS MT Medicare	$34.20
Rate for Payer: BCBS MT POS	$36.10
Rate for Payer: BCBS MT Traditional	$38.00
Rate for Payer: Cash Price	$34.20
Rate for Payer: Cigna Commercial	$36.10
Rate for Payer: Cigna Medicare	$34.20
Rate for Payer: Medicaid All Medicaid	$34.96
Rate for Payer: Medicare All Medicare	$26.60
Rate for Payer: Monida Allegiance	$36.10
Rate for Payer: Monida First Choice Health	$36.86
Rate for Payer: Monida Montana Health Co-op	$36.10
Rate for Payer: Monida PacificSource	$36.10

ANKLE SPLINT LACE-UP LG

Facility

$38.00

Service Code	HCPCS E1815
Hospital Charge Code	2893174
Hospital Revenue Code	290
Min. Negotiated Rate	$26.60
Max. Negotiated Rate	$38.00
Rate for Payer: Aetna Commercial	$36.10
Rate for Payer: Aetna Medicare	$34.20
Rate for Payer: BCBS MT CHIP	$34.20
Rate for Payer: BCBS MT Closed Plan Network	$36.10
Rate for Payer: BCBS MT HealthLink	$34.20
Rate for Payer: BCBS MT Medicare	$34.20
Rate for Payer: BCBS MT POS	$36.10
Rate for Payer: BCBS MT Traditional	$38.00
Rate for Payer: Cash Price	$34.20
Rate for Payer: Cigna Commercial	$36.10
Rate for Payer: Cigna Medicare	$34.20
Rate for Payer: Medicaid All Medicaid	$34.96
Rate for Payer: Medicare All Medicare	$26.60
Rate for Payer: Monida Allegiance	$36.10
Rate for Payer: Monida First Choice Health	$36.86
Rate for Payer: Monida Montana Health Co-op	$36.10
Rate for Payer: Monida PacificSource	$36.10

ANKLE SPLINT LACE-UP MED

Facility

$38.00

Service Code	HCPCS E1815
Hospital Charge Code	2893173
Hospital Revenue Code	290
Min. Negotiated Rate	$26.60
Max. Negotiated Rate	$38.00
Rate for Payer: Aetna Commercial	$36.10
Rate for Payer: Aetna Medicare	$34.20
Rate for Payer: BCBS MT CHIP	$34.20
Rate for Payer: BCBS MT Closed Plan Network	$36.10
Rate for Payer: BCBS MT HealthLink	$34.20
Rate for Payer: BCBS MT Medicare	$34.20
Rate for Payer: BCBS MT POS	$36.10
Rate for Payer: BCBS MT Traditional	$38.00
Rate for Payer: Cash Price	$34.20
Rate for Payer: Cigna Commercial	$36.10
Rate for Payer: Cigna Medicare	$34.20
Rate for Payer: Medicaid All Medicaid	$34.96
Rate for Payer: Medicare All Medicare	$26.60
Rate for Payer: Monida Allegiance	$36.10
Rate for Payer: Monida First Choice Health	$36.86
Rate for Payer: Monida Montana Health Co-op	$36.10
Rate for Payer: Monida PacificSource	$36.10

Know your out-of-pocket cost for care.

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