Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

PROCALCITONIN (164750)

Facility

$561.00

Service Code	HCPCS 84145
Hospital Charge Code	4084145
Hospital Revenue Code	300
Min. Negotiated Rate	$392.70
Max. Negotiated Rate	$561.00
Rate for Payer: Aetna Commercial	$532.95
Rate for Payer: Aetna Medicare	$504.90
Rate for Payer: BCBS MT CHIP	$504.90
Rate for Payer: BCBS MT Closed Plan Network	$532.95
Rate for Payer: BCBS MT HealthLink	$504.90
Rate for Payer: BCBS MT Medicare	$504.90
Rate for Payer: BCBS MT POS	$532.95
Rate for Payer: BCBS MT Traditional	$561.00
Rate for Payer: Cash Price	$504.90
Rate for Payer: Cigna Commercial	$532.95
Rate for Payer: Cigna Medicare	$504.90
Rate for Payer: Medicaid All Medicaid	$516.12
Rate for Payer: Medicare All Medicare	$392.70
Rate for Payer: Monida Allegiance	$532.95
Rate for Payer: Monida First Choice Health	$544.17
Rate for Payer: Monida Montana Health Co-op	$532.95
Rate for Payer: Monida PacificSource	$532.95

PROCALCITONIN (164750)

Facility

$561.00

Service Code	HCPCS 84145
Hospital Charge Code	4084145
Hospital Revenue Code	300
Min. Negotiated Rate	$392.70
Max. Negotiated Rate	$561.00
Rate for Payer: Aetna Commercial	$532.95
Rate for Payer: Aetna Medicare	$504.90
Rate for Payer: BCBS MT CHIP	$504.90
Rate for Payer: BCBS MT Closed Plan Network	$532.95
Rate for Payer: BCBS MT HealthLink	$504.90
Rate for Payer: BCBS MT Medicare	$504.90
Rate for Payer: BCBS MT POS	$532.95
Rate for Payer: BCBS MT Traditional	$561.00
Rate for Payer: Cash Price	$504.90
Rate for Payer: Cigna Commercial	$532.95
Rate for Payer: Cigna Medicare	$504.90
Rate for Payer: Medicaid All Medicaid	$516.12
Rate for Payer: Medicare All Medicare	$392.70
Rate for Payer: Monida Allegiance	$532.95
Rate for Payer: Monida First Choice Health	$544.17
Rate for Payer: Monida Montana Health Co-op	$532.95
Rate for Payer: Monida PacificSource	$532.95

PROCHLORPERAZINE INJ [10 MG/2 ML] VIAL

Facility

$21.00

Service Code	HCPCS J0780
Hospital Charge Code	3000403
Hospital Revenue Code	250
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 MT CHIP	$18.90
Rate for Payer: BCBS MT Closed Plan Network	$19.95
Rate for Payer: BCBS MT HealthLink	$18.90
Rate for Payer: BCBS MT Medicare	$18.90
Rate for Payer: BCBS MT POS	$19.95
Rate for Payer: BCBS MT Traditional	$21.00
Rate for Payer: Cash Price	$18.90
Rate for Payer: Cigna Commercial	$19.95
Rate for Payer: Cigna Medicare	$18.90
Rate for Payer: Medicaid All Medicaid	$19.32
Rate for Payer: Medicare All Medicare	$14.70
Rate for Payer: Monida Allegiance	$19.95
Rate for Payer: Monida First Choice Health	$20.37
Rate for Payer: Monida Montana Health Co-op	$19.95
Rate for Payer: Monida PacificSource	$19.95

PROCHLORPERAZINE INJ [10 MG/2 ML] VIAL

Facility

$21.00

Service Code	HCPCS J0780
Hospital Charge Code	3000403
Hospital Revenue Code	250
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 MT CHIP	$18.90
Rate for Payer: BCBS MT Closed Plan Network	$19.95
Rate for Payer: BCBS MT HealthLink	$18.90
Rate for Payer: BCBS MT Medicare	$18.90
Rate for Payer: BCBS MT POS	$19.95
Rate for Payer: BCBS MT Traditional	$21.00
Rate for Payer: Cash Price	$18.90
Rate for Payer: Cigna Commercial	$19.95
Rate for Payer: Cigna Medicare	$18.90
Rate for Payer: Medicaid All Medicaid	$19.32
Rate for Payer: Medicare All Medicare	$14.70
Rate for Payer: Monida Allegiance	$19.95
Rate for Payer: Monida First Choice Health	$20.37
Rate for Payer: Monida Montana Health Co-op	$19.95
Rate for Payer: Monida PacificSource	$19.95

PROCHLORPERAZINE TAB [5 MG]

Facility

$8.00

Service Code	HCPCS Q0164
Hospital Charge Code	3000404
Hospital Revenue Code	250
Min. Negotiated Rate	$5.60
Max. Negotiated Rate	$8.00
Rate for Payer: Aetna Commercial	$7.60
Rate for Payer: Aetna Medicare	$7.20
Rate for Payer: BCBS MT CHIP	$7.20
Rate for Payer: BCBS MT Closed Plan Network	$7.60
Rate for Payer: BCBS MT HealthLink	$7.20
Rate for Payer: BCBS MT Medicare	$7.20
Rate for Payer: BCBS MT POS	$7.60
Rate for Payer: BCBS MT Traditional	$8.00
Rate for Payer: Cash Price	$7.20
Rate for Payer: Cigna Commercial	$7.60
Rate for Payer: Cigna Medicare	$7.20
Rate for Payer: Medicaid All Medicaid	$7.36
Rate for Payer: Medicare All Medicare	$5.60
Rate for Payer: Monida Allegiance	$7.60
Rate for Payer: Monida First Choice Health	$7.76
Rate for Payer: Monida Montana Health Co-op	$7.60
Rate for Payer: Monida PacificSource	$7.60

PROCHLORPERAZINE TAB [5 MG]

Facility

$8.00

Service Code	HCPCS Q0164
Hospital Charge Code	3000404
Hospital Revenue Code	250
Min. Negotiated Rate	$5.60
Max. Negotiated Rate	$8.00
Rate for Payer: Aetna Commercial	$7.60
Rate for Payer: Aetna Medicare	$7.20
Rate for Payer: BCBS MT CHIP	$7.20
Rate for Payer: BCBS MT Closed Plan Network	$7.60
Rate for Payer: BCBS MT HealthLink	$7.20
Rate for Payer: BCBS MT Medicare	$7.20
Rate for Payer: BCBS MT POS	$7.60
Rate for Payer: BCBS MT Traditional	$8.00
Rate for Payer: Cash Price	$7.20
Rate for Payer: Cigna Commercial	$7.60
Rate for Payer: Cigna Medicare	$7.20
Rate for Payer: Medicaid All Medicaid	$7.36
Rate for Payer: Medicare All Medicare	$5.60
Rate for Payer: Monida Allegiance	$7.60
Rate for Payer: Monida First Choice Health	$7.76
Rate for Payer: Monida Montana Health Co-op	$7.60
Rate for Payer: Monida PacificSource	$7.60

PRO FEE APPLICATION OF FINGER SPLINT

Professional

Both

$235.00

Service Code	HCPCS 29130
Hospital Charge Code	7229130
Hospital Revenue Code	981
Min. Negotiated Rate	$164.50
Max. Negotiated Rate	$235.00
Rate for Payer: Aetna Commercial	$223.25
Rate for Payer: Aetna Medicare	$211.50
Rate for Payer: BCBS MT CHIP	$211.50
Rate for Payer: BCBS MT Closed Plan Network	$223.25
Rate for Payer: BCBS MT HealthLink	$211.50
Rate for Payer: BCBS MT Medicare	$211.50
Rate for Payer: BCBS MT POS	$223.25
Rate for Payer: BCBS MT Traditional	$235.00
Rate for Payer: Cash Price	$211.50
Rate for Payer: Cigna Commercial	$223.25
Rate for Payer: Cigna Medicare	$211.50
Rate for Payer: Medicaid All Medicaid	$216.20
Rate for Payer: Medicare All Medicare	$164.50
Rate for Payer: Monida Allegiance	$223.25
Rate for Payer: Monida First Choice Health	$227.95
Rate for Payer: Monida Montana Health Co-op	$223.25
Rate for Payer: Monida PacificSource	$223.25

PRO FEE CLSDTX IPJNT W/MAN W/O ANES26770

Professional

Both

$273.00

Service Code	HCPCS 26770
Hospital Charge Code	726770
Hospital Revenue Code	981
Min. Negotiated Rate	$191.10
Max. Negotiated Rate	$273.00
Rate for Payer: Aetna Commercial	$259.35
Rate for Payer: Aetna Medicare	$245.70
Rate for Payer: BCBS MT CHIP	$245.70
Rate for Payer: BCBS MT Closed Plan Network	$259.35
Rate for Payer: BCBS MT HealthLink	$245.70
Rate for Payer: BCBS MT Medicare	$245.70
Rate for Payer: BCBS MT POS	$259.35
Rate for Payer: BCBS MT Traditional	$273.00
Rate for Payer: Cash Price	$245.70
Rate for Payer: Cigna Commercial	$259.35
Rate for Payer: Cigna Medicare	$245.70
Rate for Payer: Medicaid All Medicaid	$251.16
Rate for Payer: Medicare All Medicare	$191.10
Rate for Payer: Monida Allegiance	$259.35
Rate for Payer: Monida First Choice Health	$264.81
Rate for Payer: Monida Montana Health Co-op	$259.35
Rate for Payer: Monida PacificSource	$259.35

PRO FEE CMPLX RPR E/N/E/L 1.1-2.5 CM

Professional

Both

$84.00

Service Code	HCPCS 13151 AQ
Hospital Charge Code	7113151
Hospital Revenue Code	981
Min. Negotiated Rate	$58.80
Max. Negotiated Rate	$84.00
Rate for Payer: Aetna Commercial	$79.80
Rate for Payer: Aetna Medicare	$75.60
Rate for Payer: BCBS MT CHIP	$75.60
Rate for Payer: BCBS MT Closed Plan Network	$79.80
Rate for Payer: BCBS MT HealthLink	$75.60
Rate for Payer: BCBS MT Medicare	$75.60
Rate for Payer: BCBS MT POS	$79.80
Rate for Payer: BCBS MT Traditional	$84.00
Rate for Payer: Cash Price	$75.60
Rate for Payer: Cigna Commercial	$79.80
Rate for Payer: Cigna Medicare	$75.60
Rate for Payer: Medicaid All Medicaid	$77.28
Rate for Payer: Medicare All Medicare	$58.80
Rate for Payer: Monida Allegiance	$79.80
Rate for Payer: Monida First Choice Health	$81.48
Rate for Payer: Monida Montana Health Co-op	$79.80
Rate for Payer: Monida PacificSource	$79.80

PROFEE COLONOSCOPY 45378

Professional

Both

$500.00

Service Code	HCPCS 45378
Hospital Charge Code	5840002
Hospital Revenue Code	960
Min. Negotiated Rate	$350.00
Max. Negotiated Rate	$485.00
Rate for Payer: Aetna Commercial	$475.00
Rate for Payer: Aetna Medicare	$450.00
Rate for Payer: Cash Price	$450.00
Rate for Payer: Medicaid All Medicaid	$460.00
Rate for Payer: Medicare All Medicare	$350.00
Rate for Payer: Monida Allegiance	$475.00
Rate for Payer: Monida First Choice Health	$485.00
Rate for Payer: Monida Montana Health Co-op	$475.00
Rate for Payer: Monida PacificSource	$475.00

PROFEE COLONOSCOPY W/ BIOPSY 45330

Professional

Both

$275.00

Service Code	HCPCS 45330
Hospital Charge Code	5840003
Hospital Revenue Code	960
Min. Negotiated Rate	$192.50
Max. Negotiated Rate	$266.75
Rate for Payer: Aetna Commercial	$261.25
Rate for Payer: Aetna Medicare	$247.50
Rate for Payer: Cash Price	$247.50
Rate for Payer: Medicaid All Medicaid	$253.00
Rate for Payer: Medicare All Medicare	$192.50
Rate for Payer: Monida Allegiance	$261.25
Rate for Payer: Monida First Choice Health	$266.75
Rate for Payer: Monida Montana Health Co-op	$261.25
Rate for Payer: Monida PacificSource	$261.25

PRO FEE DEBRIDEMENT 20SQCM OR LESS 97597

Professional

Both

$100.00

Service Code	HCPCS 97597
Hospital Charge Code	797597
Hospital Revenue Code	960
Min. Negotiated Rate	$70.00
Max. Negotiated Rate	$97.00
Rate for Payer: Aetna Commercial	$95.00
Rate for Payer: Aetna Medicare	$90.00
Rate for Payer: Cash Price	$90.00
Rate for Payer: Medicaid All Medicaid	$92.00
Rate for Payer: Medicare All Medicare	$70.00
Rate for Payer: Monida Allegiance	$95.00
Rate for Payer: Monida First Choice Health	$97.00
Rate for Payer: Monida Montana Health Co-op	$95.00
Rate for Payer: Monida PacificSource	$95.00

PRO FEE DEBRIDEMENT EA ADD 20SQCM 97598

Professional

Both

$50.00

Service Code	HCPCS 97598
Hospital Charge Code	797598
Hospital Revenue Code	982
Min. Negotiated Rate	$35.00
Max. Negotiated Rate	$48.50
Rate for Payer: Aetna Commercial	$47.50
Rate for Payer: Aetna Medicare	$45.00
Rate for Payer: Cash Price	$45.00
Rate for Payer: Medicaid All Medicaid	$46.00
Rate for Payer: Medicare All Medicare	$35.00
Rate for Payer: Monida Allegiance	$47.50
Rate for Payer: Monida First Choice Health	$48.50
Rate for Payer: Monida Montana Health Co-op	$47.50
Rate for Payer: Monida PacificSource	$47.50

PRO FEE DEBRIDE NON-SELECT W/O ANES97602

Professional

Both

$100.00

Service Code	HCPCS 97602
Hospital Charge Code	797602
Hospital Revenue Code	982
Min. Negotiated Rate	$70.00
Max. Negotiated Rate	$97.00
Rate for Payer: Aetna Commercial	$95.00
Rate for Payer: Aetna Medicare	$90.00
Rate for Payer: Cash Price	$90.00
Rate for Payer: Medicaid All Medicaid	$92.00
Rate for Payer: Medicare All Medicare	$70.00
Rate for Payer: Monida Allegiance	$95.00
Rate for Payer: Monida First Choice Health	$97.00
Rate for Payer: Monida Montana Health Co-op	$95.00
Rate for Payer: Monida PacificSource	$95.00

PRO FEE DESTRUCTION NEUROLYTIC AGT GENI

Professional

Both

$428.00

Service Code	HCPCS 64624
Hospital Charge Code	7664624
Hospital Revenue Code	964
Min. Negotiated Rate	$299.60
Max. Negotiated Rate	$428.00
Rate for Payer: Aetna Commercial	$406.60
Rate for Payer: Aetna Medicare	$385.20
Rate for Payer: BCBS MT CHIP	$385.20
Rate for Payer: BCBS MT Closed Plan Network	$406.60
Rate for Payer: BCBS MT HealthLink	$385.20
Rate for Payer: BCBS MT Medicare	$385.20
Rate for Payer: BCBS MT POS	$406.60
Rate for Payer: BCBS MT Traditional	$428.00
Rate for Payer: Cash Price	$385.20
Rate for Payer: Cigna Commercial	$406.60
Rate for Payer: Cigna Medicare	$385.20
Rate for Payer: Medicaid All Medicaid	$393.76
Rate for Payer: Medicare All Medicare	$299.60
Rate for Payer: Monida Allegiance	$406.60
Rate for Payer: Monida First Choice Health	$415.16
Rate for Payer: Monida Montana Health Co-op	$406.60
Rate for Payer: Monida PacificSource	$406.60

PRO FEE DRAIN ABSCESS, CYST DENTO 41800

Professional

Both

$63.00

Service Code	HCPCS 41800 AQ
Hospital Charge Code	741800
Hospital Revenue Code	981
Min. Negotiated Rate	$44.10
Max. Negotiated Rate	$63.00
Rate for Payer: Aetna Commercial	$59.85
Rate for Payer: Aetna Medicare	$56.70
Rate for Payer: BCBS MT CHIP	$56.70
Rate for Payer: BCBS MT Closed Plan Network	$59.85
Rate for Payer: BCBS MT HealthLink	$56.70
Rate for Payer: BCBS MT Medicare	$56.70
Rate for Payer: BCBS MT POS	$59.85
Rate for Payer: BCBS MT Traditional	$63.00
Rate for Payer: Cash Price	$56.70
Rate for Payer: Cigna Commercial	$59.85
Rate for Payer: Cigna Medicare	$56.70
Rate for Payer: Medicaid All Medicaid	$57.96
Rate for Payer: Medicare All Medicare	$44.10
Rate for Payer: Monida Allegiance	$59.85
Rate for Payer: Monida First Choice Health	$61.11
Rate for Payer: Monida Montana Health Co-op	$59.85
Rate for Payer: Monida PacificSource	$59.85

PRO FEE DRAIN/INJ JOINT/BURSA W/US 20604

Professional

Both

$103.00

Service Code	HCPCS 20604
Hospital Charge Code	720604
Hospital Revenue Code	964
Min. Negotiated Rate	$72.10
Max. Negotiated Rate	$103.00
Rate for Payer: Aetna Commercial	$97.85
Rate for Payer: Aetna Medicare	$92.70
Rate for Payer: BCBS MT CHIP	$92.70
Rate for Payer: BCBS MT Closed Plan Network	$97.85
Rate for Payer: BCBS MT HealthLink	$92.70
Rate for Payer: BCBS MT Medicare	$92.70
Rate for Payer: BCBS MT POS	$97.85
Rate for Payer: BCBS MT Traditional	$103.00
Rate for Payer: Cash Price	$92.70
Rate for Payer: Cigna Commercial	$97.85
Rate for Payer: Cigna Medicare	$92.70
Rate for Payer: Medicaid All Medicaid	$94.76
Rate for Payer: Medicare All Medicare	$72.10
Rate for Payer: Monida Allegiance	$97.85
Rate for Payer: Monida First Choice Health	$99.91
Rate for Payer: Monida Montana Health Co-op	$97.85
Rate for Payer: Monida PacificSource	$97.85

PROFEE EGD 43235

Professional

Both

$425.00

Service Code	HCPCS 43235
Hospital Charge Code	584000
Hospital Revenue Code	960
Min. Negotiated Rate	$297.50
Max. Negotiated Rate	$412.25
Rate for Payer: Aetna Commercial	$403.75
Rate for Payer: Aetna Medicare	$382.50
Rate for Payer: Cash Price	$382.50
Rate for Payer: Medicaid All Medicaid	$391.00
Rate for Payer: Medicare All Medicare	$297.50
Rate for Payer: Monida Allegiance	$403.75
Rate for Payer: Monida First Choice Health	$412.25
Rate for Payer: Monida Montana Health Co-op	$403.75
Rate for Payer: Monida PacificSource	$403.75

PROFEE EGD W/ BIOPSY 43239

Professional

Both

$560.00

Service Code	HCPCS 43239
Hospital Charge Code	5840001
Hospital Revenue Code	960
Min. Negotiated Rate	$392.00
Max. Negotiated Rate	$543.20
Rate for Payer: Aetna Commercial	$532.00
Rate for Payer: Aetna Medicare	$504.00
Rate for Payer: Cash Price	$504.00
Rate for Payer: Medicaid All Medicaid	$515.20
Rate for Payer: Medicare All Medicare	$392.00
Rate for Payer: Monida Allegiance	$532.00
Rate for Payer: Monida First Choice Health	$543.20
Rate for Payer: Monida Montana Health Co-op	$532.00
Rate for Payer: Monida PacificSource	$532.00

PRO FEE EKG 12 LEAD

Professional

Both

$51.00

Service Code	HCPCS 93010 AQ
Hospital Charge Code	793010
Hospital Revenue Code	985
Min. Negotiated Rate	$35.70
Max. Negotiated Rate	$49.47
Rate for Payer: Aetna Commercial	$48.45
Rate for Payer: Aetna Medicare	$45.90
Rate for Payer: Cash Price	$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

PRO FEE EPISTAXIS, COMPLEX

Professional

Both

$99.00

Service Code	HCPCS 30903
Hospital Charge Code	730903
Hospital Revenue Code	981
Min. Negotiated Rate	$69.30
Max. Negotiated Rate	$99.00
Rate for Payer: Aetna Commercial	$94.05
Rate for Payer: Aetna Medicare	$89.10
Rate for Payer: BCBS MT CHIP	$89.10
Rate for Payer: BCBS MT Closed Plan Network	$94.05
Rate for Payer: BCBS MT HealthLink	$89.10
Rate for Payer: BCBS MT Medicare	$89.10
Rate for Payer: BCBS MT POS	$94.05
Rate for Payer: BCBS MT Traditional	$99.00
Rate for Payer: Cash Price	$89.10
Rate for Payer: Cigna Commercial	$94.05
Rate for Payer: Cigna Medicare	$89.10
Rate for Payer: Medicaid All Medicaid	$91.08
Rate for Payer: Medicare All Medicare	$69.30
Rate for Payer: Monida Allegiance	$94.05
Rate for Payer: Monida First Choice Health	$96.03
Rate for Payer: Monida Montana Health Co-op	$94.05
Rate for Payer: Monida PacificSource	$94.05

PRO FEE EPISTAXIS, INITIAL

Professional

Both

$89.00

Service Code	HCPCS 30905
Hospital Charge Code	730905
Hospital Revenue Code	981
Min. Negotiated Rate	$62.30
Max. Negotiated Rate	$89.00
Rate for Payer: Aetna Commercial	$84.55
Rate for Payer: Aetna Medicare	$80.10
Rate for Payer: BCBS MT CHIP	$80.10
Rate for Payer: BCBS MT Closed Plan Network	$84.55
Rate for Payer: BCBS MT HealthLink	$80.10
Rate for Payer: BCBS MT Medicare	$80.10
Rate for Payer: BCBS MT POS	$84.55
Rate for Payer: BCBS MT Traditional	$89.00
Rate for Payer: Cash Price	$80.10
Rate for Payer: Cigna Commercial	$84.55
Rate for Payer: Cigna Medicare	$80.10
Rate for Payer: Medicaid All Medicaid	$81.88
Rate for Payer: Medicare All Medicare	$62.30
Rate for Payer: Monida Allegiance	$84.55
Rate for Payer: Monida First Choice Health	$86.33
Rate for Payer: Monida Montana Health Co-op	$84.55
Rate for Payer: Monida PacificSource	$84.55

PRO FEE EPISTAXIS, SIMPLE

Professional

Both

$89.00

Service Code	HCPCS 30901
Hospital Charge Code	730901
Hospital Revenue Code	981
Min. Negotiated Rate	$62.30
Max. Negotiated Rate	$89.00
Rate for Payer: Aetna Commercial	$84.55
Rate for Payer: Aetna Medicare	$80.10
Rate for Payer: BCBS MT CHIP	$80.10
Rate for Payer: BCBS MT Closed Plan Network	$84.55
Rate for Payer: BCBS MT HealthLink	$80.10
Rate for Payer: BCBS MT Medicare	$80.10
Rate for Payer: BCBS MT POS	$84.55
Rate for Payer: BCBS MT Traditional	$89.00
Rate for Payer: Cash Price	$80.10
Rate for Payer: Cigna Commercial	$84.55
Rate for Payer: Cigna Medicare	$80.10
Rate for Payer: Medicaid All Medicaid	$81.88
Rate for Payer: Medicare All Medicare	$62.30
Rate for Payer: Monida Allegiance	$84.55
Rate for Payer: Monida First Choice Health	$86.33
Rate for Payer: Monida Montana Health Co-op	$84.55
Rate for Payer: Monida PacificSource	$84.55

PRO FEE ER APPLICATION OF SHORT LEG SPLI

Professional

Both

$322.00

Service Code	HCPCS 29515
Hospital Charge Code	7229515
Hospital Revenue Code	981
Min. Negotiated Rate	$225.40
Max. Negotiated Rate	$322.00
Rate for Payer: Aetna Commercial	$305.90
Rate for Payer: Aetna Medicare	$289.80
Rate for Payer: BCBS MT CHIP	$289.80
Rate for Payer: BCBS MT Closed Plan Network	$305.90
Rate for Payer: BCBS MT HealthLink	$289.80
Rate for Payer: BCBS MT Medicare	$289.80
Rate for Payer: BCBS MT POS	$305.90
Rate for Payer: BCBS MT Traditional	$322.00
Rate for Payer: Cash Price	$289.80
Rate for Payer: Cigna Commercial	$305.90
Rate for Payer: Cigna Medicare	$289.80
Rate for Payer: Medicaid All Medicaid	$296.24
Rate for Payer: Medicare All Medicare	$225.40
Rate for Payer: Monida Allegiance	$305.90
Rate for Payer: Monida First Choice Health	$312.34
Rate for Payer: Monida Montana Health Co-op	$305.90
Rate for Payer: Monida PacificSource	$305.90

PRO FEE ER APPLICATION SPLINT LONG 29105

Professional

Both

$85.00

Service Code	HCPCS 29105
Hospital Charge Code	729105
Hospital Revenue Code	981
Min. Negotiated Rate	$59.50
Max. Negotiated Rate	$85.00
Rate for Payer: Aetna Commercial	$80.75
Rate for Payer: Aetna Medicare	$76.50
Rate for Payer: BCBS MT CHIP	$76.50
Rate for Payer: BCBS MT Closed Plan Network	$80.75
Rate for Payer: BCBS MT HealthLink	$76.50
Rate for Payer: BCBS MT Medicare	$76.50
Rate for Payer: BCBS MT POS	$80.75
Rate for Payer: BCBS MT Traditional	$85.00
Rate for Payer: Cash Price	$76.50
Rate for Payer: Cigna Commercial	$80.75
Rate for Payer: Cigna Medicare	$76.50
Rate for Payer: Medicaid All Medicaid	$78.20
Rate for Payer: Medicare All Medicare	$59.50
Rate for Payer: Monida Allegiance	$80.75
Rate for Payer: Monida First Choice Health	$82.45
Rate for Payer: Monida Montana Health Co-op	$80.75
Rate for Payer: Monida PacificSource	$80.75

Know your out-of-pocket cost for care.

All Charges