Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

OP INJ TRANSFOR L/S ADD 64484

Facility

$840.00

Service Code	HCPCS 64484
Hospital Charge Code	1564484
Hospital Revenue Code	761
Min. Negotiated Rate	$588.00
Max. Negotiated Rate	$840.00
Rate for Payer: Aetna Commercial	$798.00
Rate for Payer: Aetna Medicare	$756.00
Rate for Payer: BCBS MT CHIP	$756.00
Rate for Payer: BCBS MT Closed Plan Network	$798.00
Rate for Payer: BCBS MT HealthLink	$756.00
Rate for Payer: BCBS MT Medicare	$756.00
Rate for Payer: BCBS MT POS	$798.00
Rate for Payer: BCBS MT Traditional	$840.00
Rate for Payer: Cash Price	$756.00
Rate for Payer: Cigna Commercial	$798.00
Rate for Payer: Cigna Medicare	$756.00
Rate for Payer: Medicaid All Medicaid	$772.80
Rate for Payer: Medicare All Medicare	$588.00
Rate for Payer: Monida Allegiance	$798.00
Rate for Payer: Monida First Choice Health	$814.80
Rate for Payer: Monida Montana Health Co-op	$798.00
Rate for Payer: Monida PacificSource	$798.00

OP INJ TRANSFOR L/S ADD 64484

Facility

$840.00

Service Code	HCPCS 64484
Hospital Charge Code	1564484
Hospital Revenue Code	761
Min. Negotiated Rate	$588.00
Max. Negotiated Rate	$840.00
Rate for Payer: Aetna Commercial	$798.00
Rate for Payer: Aetna Medicare	$756.00
Rate for Payer: BCBS MT CHIP	$756.00
Rate for Payer: BCBS MT Closed Plan Network	$798.00
Rate for Payer: BCBS MT HealthLink	$756.00
Rate for Payer: BCBS MT Medicare	$756.00
Rate for Payer: BCBS MT POS	$798.00
Rate for Payer: BCBS MT Traditional	$840.00
Rate for Payer: Cash Price	$756.00
Rate for Payer: Cigna Commercial	$798.00
Rate for Payer: Cigna Medicare	$756.00
Rate for Payer: Medicaid All Medicaid	$772.80
Rate for Payer: Medicare All Medicare	$588.00
Rate for Payer: Monida Allegiance	$798.00
Rate for Payer: Monida First Choice Health	$814.80
Rate for Payer: Monida Montana Health Co-op	$798.00
Rate for Payer: Monida PacificSource	$798.00

OP INTO/INJ GENICULAR NERVE BRANCH 64454

Facility

$656.00

Service Code	HCPCS 64454
Hospital Charge Code	1564454
Hospital Revenue Code	761
Min. Negotiated Rate	$459.20
Max. Negotiated Rate	$656.00
Rate for Payer: Aetna Commercial	$623.20
Rate for Payer: Aetna Medicare	$590.40
Rate for Payer: BCBS MT CHIP	$590.40
Rate for Payer: BCBS MT Closed Plan Network	$623.20
Rate for Payer: BCBS MT HealthLink	$590.40
Rate for Payer: BCBS MT Medicare	$590.40
Rate for Payer: BCBS MT POS	$623.20
Rate for Payer: BCBS MT Traditional	$656.00
Rate for Payer: Cash Price	$590.40
Rate for Payer: Cigna Commercial	$623.20
Rate for Payer: Cigna Medicare	$590.40
Rate for Payer: Medicaid All Medicaid	$603.52
Rate for Payer: Medicare All Medicare	$459.20
Rate for Payer: Monida Allegiance	$623.20
Rate for Payer: Monida First Choice Health	$636.32
Rate for Payer: Monida Montana Health Co-op	$623.20
Rate for Payer: Monida PacificSource	$623.20

OP INTO/INJ GENICULAR NERVE BRANCH 64454

Facility

$656.00

Service Code	HCPCS 64454
Hospital Charge Code	1564454
Hospital Revenue Code	761
Min. Negotiated Rate	$459.20
Max. Negotiated Rate	$656.00
Rate for Payer: Aetna Commercial	$623.20
Rate for Payer: Aetna Medicare	$590.40
Rate for Payer: BCBS MT CHIP	$590.40
Rate for Payer: BCBS MT Closed Plan Network	$623.20
Rate for Payer: BCBS MT HealthLink	$590.40
Rate for Payer: BCBS MT Medicare	$590.40
Rate for Payer: BCBS MT POS	$623.20
Rate for Payer: BCBS MT Traditional	$656.00
Rate for Payer: Cash Price	$590.40
Rate for Payer: Cigna Commercial	$623.20
Rate for Payer: Cigna Medicare	$590.40
Rate for Payer: Medicaid All Medicaid	$603.52
Rate for Payer: Medicare All Medicare	$459.20
Rate for Payer: Monida Allegiance	$623.20
Rate for Payer: Monida First Choice Health	$636.32
Rate for Payer: Monida Montana Health Co-op	$623.20
Rate for Payer: Monida PacificSource	$623.20

OP MAJOR JOINT INJ W/O US 20610

Facility

$928.00

Service Code	HCPCS 20610
Hospital Charge Code	520610
Hospital Revenue Code	761
Min. Negotiated Rate	$649.60
Max. Negotiated Rate	$928.00
Rate for Payer: Aetna Commercial	$881.60
Rate for Payer: Aetna Medicare	$835.20
Rate for Payer: BCBS MT CHIP	$835.20
Rate for Payer: BCBS MT Closed Plan Network	$881.60
Rate for Payer: BCBS MT HealthLink	$835.20
Rate for Payer: BCBS MT Medicare	$835.20
Rate for Payer: BCBS MT POS	$881.60
Rate for Payer: BCBS MT Traditional	$928.00
Rate for Payer: Cash Price	$835.20
Rate for Payer: Cigna Commercial	$881.60
Rate for Payer: Cigna Medicare	$835.20
Rate for Payer: Medicaid All Medicaid	$853.76
Rate for Payer: Medicare All Medicare	$649.60
Rate for Payer: Monida Allegiance	$881.60
Rate for Payer: Monida First Choice Health	$900.16
Rate for Payer: Monida Montana Health Co-op	$881.60
Rate for Payer: Monida PacificSource	$881.60

OP MAJOR JOINT INJ W/O US 20610

Facility

$928.00

Service Code	HCPCS 20610
Hospital Charge Code	520610
Hospital Revenue Code	761
Min. Negotiated Rate	$649.60
Max. Negotiated Rate	$928.00
Rate for Payer: Aetna Commercial	$881.60
Rate for Payer: Aetna Medicare	$835.20
Rate for Payer: BCBS MT CHIP	$835.20
Rate for Payer: BCBS MT Closed Plan Network	$881.60
Rate for Payer: BCBS MT HealthLink	$835.20
Rate for Payer: BCBS MT Medicare	$835.20
Rate for Payer: BCBS MT POS	$881.60
Rate for Payer: BCBS MT Traditional	$928.00
Rate for Payer: Cash Price	$835.20
Rate for Payer: Cigna Commercial	$881.60
Rate for Payer: Cigna Medicare	$835.20
Rate for Payer: Medicaid All Medicaid	$853.76
Rate for Payer: Medicare All Medicare	$649.60
Rate for Payer: Monida Allegiance	$881.60
Rate for Payer: Monida First Choice Health	$900.16
Rate for Payer: Monida Montana Health Co-op	$881.60
Rate for Payer: Monida PacificSource	$881.60

OP MOD CON SEDATION ADDTL 15 MIN 99153

Facility

$122.00

Service Code	HCPCS 99153
Hospital Charge Code	1599153
Hospital Revenue Code	370
Min. Negotiated Rate	$85.40
Max. Negotiated Rate	$122.00
Rate for Payer: Aetna Commercial	$115.90
Rate for Payer: Aetna Medicare	$109.80
Rate for Payer: BCBS MT CHIP	$109.80
Rate for Payer: BCBS MT Closed Plan Network	$115.90
Rate for Payer: BCBS MT HealthLink	$109.80
Rate for Payer: BCBS MT Medicare	$109.80
Rate for Payer: BCBS MT POS	$115.90
Rate for Payer: BCBS MT Traditional	$122.00
Rate for Payer: Cash Price	$109.80
Rate for Payer: Cigna Commercial	$115.90
Rate for Payer: Cigna Medicare	$109.80
Rate for Payer: Medicaid All Medicaid	$112.24
Rate for Payer: Medicare All Medicare	$85.40
Rate for Payer: Monida Allegiance	$115.90
Rate for Payer: Monida First Choice Health	$118.34
Rate for Payer: Monida Montana Health Co-op	$115.90
Rate for Payer: Monida PacificSource	$115.90

OP MOD CON SEDATION ADDTL 15 MIN 99153

Facility

$122.00

Service Code	HCPCS 99153
Hospital Charge Code	1599153
Hospital Revenue Code	370
Min. Negotiated Rate	$85.40
Max. Negotiated Rate	$122.00
Rate for Payer: Aetna Commercial	$115.90
Rate for Payer: Aetna Medicare	$109.80
Rate for Payer: BCBS MT CHIP	$109.80
Rate for Payer: BCBS MT Closed Plan Network	$115.90
Rate for Payer: BCBS MT HealthLink	$109.80
Rate for Payer: BCBS MT Medicare	$109.80
Rate for Payer: BCBS MT POS	$115.90
Rate for Payer: BCBS MT Traditional	$122.00
Rate for Payer: Cash Price	$109.80
Rate for Payer: Cigna Commercial	$115.90
Rate for Payer: Cigna Medicare	$109.80
Rate for Payer: Medicaid All Medicaid	$112.24
Rate for Payer: Medicare All Medicare	$85.40
Rate for Payer: Monida Allegiance	$115.90
Rate for Payer: Monida First Choice Health	$118.34
Rate for Payer: Monida Montana Health Co-op	$115.90
Rate for Payer: Monida PacificSource	$115.90

OPO DIRECT ADMISSION

Facility

$186.00

Service Code	HCPCS G0379
Hospital Charge Code	210053
Hospital Revenue Code	762
Min. Negotiated Rate	$130.20
Max. Negotiated Rate	$186.00
Rate for Payer: Aetna Commercial	$176.70
Rate for Payer: Aetna Medicare	$167.40
Rate for Payer: BCBS MT CHIP	$167.40
Rate for Payer: BCBS MT Closed Plan Network	$176.70
Rate for Payer: BCBS MT HealthLink	$167.40
Rate for Payer: BCBS MT Medicare	$167.40
Rate for Payer: BCBS MT POS	$176.70
Rate for Payer: BCBS MT Traditional	$186.00
Rate for Payer: Cash Price	$167.40
Rate for Payer: Cigna Commercial	$176.70
Rate for Payer: Cigna Medicare	$167.40
Rate for Payer: Medicaid All Medicaid	$171.12
Rate for Payer: Medicare All Medicare	$130.20
Rate for Payer: Monida Allegiance	$176.70
Rate for Payer: Monida First Choice Health	$180.42
Rate for Payer: Monida Montana Health Co-op	$176.70
Rate for Payer: Monida PacificSource	$176.70

OPO DIRECT ADMISSION

Facility

$186.00

Service Code	HCPCS G0379
Hospital Charge Code	210053
Hospital Revenue Code	762
Min. Negotiated Rate	$130.20
Max. Negotiated Rate	$186.00
Rate for Payer: Aetna Commercial	$176.70
Rate for Payer: Aetna Medicare	$167.40
Rate for Payer: BCBS MT CHIP	$167.40
Rate for Payer: BCBS MT Closed Plan Network	$176.70
Rate for Payer: BCBS MT HealthLink	$167.40
Rate for Payer: BCBS MT Medicare	$167.40
Rate for Payer: BCBS MT POS	$176.70
Rate for Payer: BCBS MT Traditional	$186.00
Rate for Payer: Cash Price	$167.40
Rate for Payer: Cigna Commercial	$176.70
Rate for Payer: Cigna Medicare	$167.40
Rate for Payer: Medicaid All Medicaid	$171.12
Rate for Payer: Medicare All Medicare	$130.20
Rate for Payer: Monida Allegiance	$176.70
Rate for Payer: Monida First Choice Health	$180.42
Rate for Payer: Monida Montana Health Co-op	$176.70
Rate for Payer: Monida PacificSource	$176.70

OPO FIRST HOUR

Facility

$186.00

Service Code	HCPCS G0378
Hospital Charge Code	210051
Hospital Revenue Code	762
Min. Negotiated Rate	$130.20
Max. Negotiated Rate	$186.00
Rate for Payer: Aetna Commercial	$176.70
Rate for Payer: Aetna Medicare	$167.40
Rate for Payer: BCBS MT CHIP	$167.40
Rate for Payer: BCBS MT Closed Plan Network	$176.70
Rate for Payer: BCBS MT HealthLink	$167.40
Rate for Payer: BCBS MT Medicare	$167.40
Rate for Payer: BCBS MT POS	$176.70
Rate for Payer: BCBS MT Traditional	$186.00
Rate for Payer: Cash Price	$167.40
Rate for Payer: Cigna Commercial	$176.70
Rate for Payer: Cigna Medicare	$167.40
Rate for Payer: Medicaid All Medicaid	$171.12
Rate for Payer: Medicare All Medicare	$130.20
Rate for Payer: Monida Allegiance	$176.70
Rate for Payer: Monida First Choice Health	$180.42
Rate for Payer: Monida Montana Health Co-op	$176.70
Rate for Payer: Monida PacificSource	$176.70

OPO FIRST HOUR

Facility

$186.00

Service Code	HCPCS G0378
Hospital Charge Code	210051
Hospital Revenue Code	762
Min. Negotiated Rate	$130.20
Max. Negotiated Rate	$186.00
Rate for Payer: Aetna Commercial	$176.70
Rate for Payer: Aetna Medicare	$167.40
Rate for Payer: BCBS MT CHIP	$167.40
Rate for Payer: BCBS MT Closed Plan Network	$176.70
Rate for Payer: BCBS MT HealthLink	$167.40
Rate for Payer: BCBS MT Medicare	$167.40
Rate for Payer: BCBS MT POS	$176.70
Rate for Payer: BCBS MT Traditional	$186.00
Rate for Payer: Cash Price	$167.40
Rate for Payer: Cigna Commercial	$176.70
Rate for Payer: Cigna Medicare	$167.40
Rate for Payer: Medicaid All Medicaid	$171.12
Rate for Payer: Medicare All Medicare	$130.20
Rate for Payer: Monida Allegiance	$176.70
Rate for Payer: Monida First Choice Health	$180.42
Rate for Payer: Monida Montana Health Co-op	$176.70
Rate for Payer: Monida PacificSource	$176.70

OPO PER HOUR 2 OR MORE

Facility

$49.00

Service Code	HCPCS G0378
Hospital Charge Code	210052
Hospital Revenue Code	762
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

OPO PER HOUR 2 OR MORE

Facility

$49.00

Service Code	HCPCS G0378
Hospital Charge Code	210052
Hospital Revenue Code	762
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

OP- PM MOD CONCSED >5 YR 1ST 15MIN 99152

Facility

$312.00

Service Code	HCPCS 99152
Hospital Charge Code	1599152
Hospital Revenue Code	370
Min. Negotiated Rate	$218.40
Max. Negotiated Rate	$312.00
Rate for Payer: Aetna Commercial	$296.40
Rate for Payer: Aetna Medicare	$280.80
Rate for Payer: BCBS MT CHIP	$280.80
Rate for Payer: BCBS MT Closed Plan Network	$296.40
Rate for Payer: BCBS MT HealthLink	$280.80
Rate for Payer: BCBS MT Medicare	$280.80
Rate for Payer: BCBS MT POS	$296.40
Rate for Payer: BCBS MT Traditional	$312.00
Rate for Payer: Cash Price	$280.80
Rate for Payer: Cigna Commercial	$296.40
Rate for Payer: Cigna Medicare	$280.80
Rate for Payer: Medicaid All Medicaid	$287.04
Rate for Payer: Medicare All Medicare	$218.40
Rate for Payer: Monida Allegiance	$296.40
Rate for Payer: Monida First Choice Health	$302.64
Rate for Payer: Monida Montana Health Co-op	$296.40
Rate for Payer: Monida PacificSource	$296.40

OP- PM MOD CONCSED >5 YR 1ST 15MIN 99152

Facility

$312.00

Service Code	HCPCS 99152
Hospital Charge Code	1599152
Hospital Revenue Code	370
Min. Negotiated Rate	$218.40
Max. Negotiated Rate	$312.00
Rate for Payer: Aetna Commercial	$296.40
Rate for Payer: Aetna Medicare	$280.80
Rate for Payer: BCBS MT CHIP	$280.80
Rate for Payer: BCBS MT Closed Plan Network	$296.40
Rate for Payer: BCBS MT HealthLink	$280.80
Rate for Payer: BCBS MT Medicare	$280.80
Rate for Payer: BCBS MT POS	$296.40
Rate for Payer: BCBS MT Traditional	$312.00
Rate for Payer: Cash Price	$280.80
Rate for Payer: Cigna Commercial	$296.40
Rate for Payer: Cigna Medicare	$280.80
Rate for Payer: Medicaid All Medicaid	$287.04
Rate for Payer: Medicare All Medicare	$218.40
Rate for Payer: Monida Allegiance	$296.40
Rate for Payer: Monida First Choice Health	$302.64
Rate for Payer: Monida Montana Health Co-op	$296.40
Rate for Payer: Monida PacificSource	$296.40

OP PRO FEE INJ ANE AGEN AXILLARY

Professional

Both

$499.00

Service Code	HCPCS 64417 GF
Hospital Charge Code	764417
Hospital Revenue Code	969
Min. Negotiated Rate	$349.30
Max. Negotiated Rate	$484.03
Rate for Payer: Aetna Commercial	$474.05
Rate for Payer: Aetna Medicare	$449.10
Rate for Payer: Cash Price	$449.10
Rate for Payer: Medicaid All Medicaid	$459.08
Rate for Payer: Medicare All Medicare	$349.30
Rate for Payer: Monida Allegiance	$474.05
Rate for Payer: Monida First Choice Health	$484.03
Rate for Payer: Monida Montana Health Co-op	$474.05
Rate for Payer: Monida PacificSource	$474.05

OPSITE DRESSING 5.5X4

Facility

$13.00

Hospital Charge Code	80030139
Hospital Revenue Code	270
Min. Negotiated Rate	$9.10
Max. Negotiated Rate	$13.00
Rate for Payer: Aetna Commercial	$12.35
Rate for Payer: Aetna Medicare	$11.70
Rate for Payer: BCBS MT CHIP	$11.70
Rate for Payer: BCBS MT Closed Plan Network	$12.35
Rate for Payer: BCBS MT HealthLink	$11.70
Rate for Payer: BCBS MT Medicare	$11.70
Rate for Payer: BCBS MT POS	$12.35
Rate for Payer: BCBS MT Traditional	$13.00
Rate for Payer: Cash Price	$11.70
Rate for Payer: Cigna Commercial	$12.35
Rate for Payer: Cigna Medicare	$11.70
Rate for Payer: Medicaid All Medicaid	$11.96
Rate for Payer: Medicare All Medicare	$9.10
Rate for Payer: Monida Allegiance	$12.35
Rate for Payer: Monida First Choice Health	$12.61
Rate for Payer: Monida Montana Health Co-op	$12.35
Rate for Payer: Monida PacificSource	$12.35

OPSITE DRESSING 5.5X4

Facility

$13.00

Hospital Charge Code	80030139
Hospital Revenue Code	270
Min. Negotiated Rate	$9.10
Max. Negotiated Rate	$13.00
Rate for Payer: Aetna Commercial	$12.35
Rate for Payer: Aetna Medicare	$11.70
Rate for Payer: BCBS MT CHIP	$11.70
Rate for Payer: BCBS MT Closed Plan Network	$12.35
Rate for Payer: BCBS MT HealthLink	$11.70
Rate for Payer: BCBS MT Medicare	$11.70
Rate for Payer: BCBS MT POS	$12.35
Rate for Payer: BCBS MT Traditional	$13.00
Rate for Payer: Cash Price	$11.70
Rate for Payer: Cigna Commercial	$12.35
Rate for Payer: Cigna Medicare	$11.70
Rate for Payer: Medicaid All Medicaid	$11.96
Rate for Payer: Medicare All Medicare	$9.10
Rate for Payer: Monida Allegiance	$12.35
Rate for Payer: Monida First Choice Health	$12.61
Rate for Payer: Monida Montana Health Co-op	$12.35
Rate for Payer: Monida PacificSource	$12.35

OPTIFOAM 4X4 ADHESIVE

Facility

$36.00

Hospital Charge Code	80030700
Hospital Revenue Code	272
Min. Negotiated Rate	$25.20
Max. Negotiated Rate	$36.00
Rate for Payer: Aetna Commercial	$34.20
Rate for Payer: Aetna Medicare	$32.40
Rate for Payer: BCBS MT CHIP	$32.40
Rate for Payer: BCBS MT Closed Plan Network	$34.20
Rate for Payer: BCBS MT HealthLink	$32.40
Rate for Payer: BCBS MT Medicare	$32.40
Rate for Payer: BCBS MT POS	$34.20
Rate for Payer: BCBS MT Traditional	$36.00
Rate for Payer: Cash Price	$32.40
Rate for Payer: Cigna Commercial	$34.20
Rate for Payer: Cigna Medicare	$32.40
Rate for Payer: Medicaid All Medicaid	$33.12
Rate for Payer: Medicare All Medicare	$25.20
Rate for Payer: Monida Allegiance	$34.20
Rate for Payer: Monida First Choice Health	$34.92
Rate for Payer: Monida Montana Health Co-op	$34.20
Rate for Payer: Monida PacificSource	$34.20

OPTIFOAM 4X4 ADHESIVE

Facility

$36.00

Hospital Charge Code	80030700
Hospital Revenue Code	272
Min. Negotiated Rate	$25.20
Max. Negotiated Rate	$36.00
Rate for Payer: Aetna Commercial	$34.20
Rate for Payer: Aetna Medicare	$32.40
Rate for Payer: BCBS MT CHIP	$32.40
Rate for Payer: BCBS MT Closed Plan Network	$34.20
Rate for Payer: BCBS MT HealthLink	$32.40
Rate for Payer: BCBS MT Medicare	$32.40
Rate for Payer: BCBS MT POS	$34.20
Rate for Payer: BCBS MT Traditional	$36.00
Rate for Payer: Cash Price	$32.40
Rate for Payer: Cigna Commercial	$34.20
Rate for Payer: Cigna Medicare	$32.40
Rate for Payer: Medicaid All Medicaid	$33.12
Rate for Payer: Medicare All Medicare	$25.20
Rate for Payer: Monida Allegiance	$34.20
Rate for Payer: Monida First Choice Health	$34.92
Rate for Payer: Monida Montana Health Co-op	$34.20
Rate for Payer: Monida PacificSource	$34.20

OPTIFOAM GENTLE SILICONE FACE FOAM 8X8

Facility

$36.00

Hospital Charge Code	80030701
Hospital Revenue Code	272
Min. Negotiated Rate	$25.20
Max. Negotiated Rate	$36.00
Rate for Payer: Aetna Commercial	$34.20
Rate for Payer: Aetna Medicare	$32.40
Rate for Payer: BCBS MT CHIP	$32.40
Rate for Payer: BCBS MT Closed Plan Network	$34.20
Rate for Payer: BCBS MT HealthLink	$32.40
Rate for Payer: BCBS MT Medicare	$32.40
Rate for Payer: BCBS MT POS	$34.20
Rate for Payer: BCBS MT Traditional	$36.00
Rate for Payer: Cash Price	$32.40
Rate for Payer: Cigna Commercial	$34.20
Rate for Payer: Cigna Medicare	$32.40
Rate for Payer: Medicaid All Medicaid	$33.12
Rate for Payer: Medicare All Medicare	$25.20
Rate for Payer: Monida Allegiance	$34.20
Rate for Payer: Monida First Choice Health	$34.92
Rate for Payer: Monida Montana Health Co-op	$34.20
Rate for Payer: Monida PacificSource	$34.20

OPTIFOAM GENTLE SILICONE FACE FOAM 8X8

Facility

$36.00

Hospital Charge Code	80030701
Hospital Revenue Code	272
Min. Negotiated Rate	$25.20
Max. Negotiated Rate	$36.00
Rate for Payer: Aetna Commercial	$34.20
Rate for Payer: Aetna Medicare	$32.40
Rate for Payer: BCBS MT CHIP	$32.40
Rate for Payer: BCBS MT Closed Plan Network	$34.20
Rate for Payer: BCBS MT HealthLink	$32.40
Rate for Payer: BCBS MT Medicare	$32.40
Rate for Payer: BCBS MT POS	$34.20
Rate for Payer: BCBS MT Traditional	$36.00
Rate for Payer: Cash Price	$32.40
Rate for Payer: Cigna Commercial	$34.20
Rate for Payer: Cigna Medicare	$32.40
Rate for Payer: Medicaid All Medicaid	$33.12
Rate for Payer: Medicare All Medicare	$25.20
Rate for Payer: Monida Allegiance	$34.20
Rate for Payer: Monida First Choice Health	$34.92
Rate for Payer: Monida Montana Health Co-op	$34.20
Rate for Payer: Monida PacificSource	$34.20

OPTIPORE SPONGE

Facility

$9.00

Hospital Charge Code	80041599
Hospital Revenue Code	270
Min. Negotiated Rate	$6.30
Max. Negotiated Rate	$9.00
Rate for Payer: Aetna Commercial	$8.55
Rate for Payer: Aetna Medicare	$8.10
Rate for Payer: BCBS MT CHIP	$8.10
Rate for Payer: BCBS MT Closed Plan Network	$8.55
Rate for Payer: BCBS MT HealthLink	$8.10
Rate for Payer: BCBS MT Medicare	$8.10
Rate for Payer: BCBS MT POS	$8.55
Rate for Payer: BCBS MT Traditional	$9.00
Rate for Payer: Cash Price	$8.10
Rate for Payer: Cigna Commercial	$8.55
Rate for Payer: Cigna Medicare	$8.10
Rate for Payer: Medicaid All Medicaid	$8.28
Rate for Payer: Medicare All Medicare	$6.30
Rate for Payer: Monida Allegiance	$8.55
Rate for Payer: Monida First Choice Health	$8.73
Rate for Payer: Monida Montana Health Co-op	$8.55
Rate for Payer: Monida PacificSource	$8.55

OPTIPORE SPONGE

Facility

$9.00

Hospital Charge Code	80041599
Hospital Revenue Code	270
Min. Negotiated Rate	$6.30
Max. Negotiated Rate	$9.00
Rate for Payer: Aetna Commercial	$8.55
Rate for Payer: Aetna Medicare	$8.10
Rate for Payer: BCBS MT CHIP	$8.10
Rate for Payer: BCBS MT Closed Plan Network	$8.55
Rate for Payer: BCBS MT HealthLink	$8.10
Rate for Payer: BCBS MT Medicare	$8.10
Rate for Payer: BCBS MT POS	$8.55
Rate for Payer: BCBS MT Traditional	$9.00
Rate for Payer: Cash Price	$8.10
Rate for Payer: Cigna Commercial	$8.55
Rate for Payer: Cigna Medicare	$8.10
Rate for Payer: Medicaid All Medicaid	$8.28
Rate for Payer: Medicare All Medicare	$6.30
Rate for Payer: Monida Allegiance	$8.55
Rate for Payer: Monida First Choice Health	$8.73
Rate for Payer: Monida Montana Health Co-op	$8.55
Rate for Payer: Monida PacificSource	$8.55

Know your out-of-pocket cost for care.

All Charges