Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

PRO FEE OP INJ SI JOINT W/IMAGE 27096

Professional

Both

$430.00

Service Code	HCPCS 27096 GF
Hospital Charge Code	727096
Hospital Revenue Code	964
Min. Negotiated Rate	$301.00
Max. Negotiated Rate	$430.00
Rate for Payer: Aetna Commercial	$408.50
Rate for Payer: Aetna Medicare	$387.00
Rate for Payer: BCBS MT CHIP	$387.00
Rate for Payer: BCBS MT Closed Plan Network	$408.50
Rate for Payer: BCBS MT HealthLink	$387.00
Rate for Payer: BCBS MT Medicare	$387.00
Rate for Payer: BCBS MT POS	$408.50
Rate for Payer: BCBS MT Traditional	$430.00
Rate for Payer: Cash Price	$387.00
Rate for Payer: Cigna Commercial	$408.50
Rate for Payer: Cigna Medicare	$387.00
Rate for Payer: Medicaid All Medicaid	$395.60
Rate for Payer: Medicare All Medicare	$301.00
Rate for Payer: Monida Allegiance	$408.50
Rate for Payer: Monida First Choice Health	$417.10
Rate for Payer: Monida Montana Health Co-op	$408.50
Rate for Payer: Monida PacificSource	$408.50

PRO FEE OP INJ SPHENOPALGANG BLOC 64505

Professional

Both

$554.00

Service Code	HCPCS 64505
Hospital Charge Code	764505
Hospital Revenue Code	964
Min. Negotiated Rate	$387.80
Max. Negotiated Rate	$554.00
Rate for Payer: Aetna Commercial	$526.30
Rate for Payer: Aetna Medicare	$498.60
Rate for Payer: BCBS MT CHIP	$498.60
Rate for Payer: BCBS MT Closed Plan Network	$526.30
Rate for Payer: BCBS MT HealthLink	$498.60
Rate for Payer: BCBS MT Medicare	$498.60
Rate for Payer: BCBS MT POS	$526.30
Rate for Payer: BCBS MT Traditional	$554.00
Rate for Payer: Cash Price	$498.60
Rate for Payer: Cigna Commercial	$526.30
Rate for Payer: Cigna Medicare	$498.60
Rate for Payer: Medicaid All Medicaid	$509.68
Rate for Payer: Medicare All Medicare	$387.80
Rate for Payer: Monida Allegiance	$526.30
Rate for Payer: Monida First Choice Health	$537.38
Rate for Payer: Monida Montana Health Co-op	$526.30
Rate for Payer: Monida PacificSource	$526.30

PRO FEE OP INJ STELLATE GANG BLOCK 64510

Professional

Both

$395.00

Service Code	HCPCS 64510
Hospital Charge Code	764510
Hospital Revenue Code	964
Min. Negotiated Rate	$276.50
Max. Negotiated Rate	$395.00
Rate for Payer: Aetna Commercial	$375.25
Rate for Payer: Aetna Medicare	$355.50
Rate for Payer: BCBS MT CHIP	$355.50
Rate for Payer: BCBS MT Closed Plan Network	$375.25
Rate for Payer: BCBS MT HealthLink	$355.50
Rate for Payer: BCBS MT Medicare	$355.50
Rate for Payer: BCBS MT POS	$375.25
Rate for Payer: BCBS MT Traditional	$395.00
Rate for Payer: Cash Price	$355.50
Rate for Payer: Cigna Commercial	$375.25
Rate for Payer: Cigna Medicare	$355.50
Rate for Payer: Medicaid All Medicaid	$363.40
Rate for Payer: Medicare All Medicare	$276.50
Rate for Payer: Monida Allegiance	$375.25
Rate for Payer: Monida First Choice Health	$383.15
Rate for Payer: Monida Montana Health Co-op	$375.25
Rate for Payer: Monida PacificSource	$375.25

PRO FEE OP INJ SUPER HYPOGSTRC PLX 64517

Professional

Both

$654.00

Service Code	HCPCS 64517
Hospital Charge Code	764517
Hospital Revenue Code	964
Min. Negotiated Rate	$457.80
Max. Negotiated Rate	$654.00
Rate for Payer: Aetna Commercial	$621.30
Rate for Payer: Aetna Medicare	$588.60
Rate for Payer: BCBS MT CHIP	$588.60
Rate for Payer: BCBS MT Closed Plan Network	$621.30
Rate for Payer: BCBS MT HealthLink	$588.60
Rate for Payer: BCBS MT Medicare	$588.60
Rate for Payer: BCBS MT POS	$621.30
Rate for Payer: BCBS MT Traditional	$654.00
Rate for Payer: Cash Price	$588.60
Rate for Payer: Cigna Commercial	$621.30
Rate for Payer: Cigna Medicare	$588.60
Rate for Payer: Medicaid All Medicaid	$601.68
Rate for Payer: Medicare All Medicare	$457.80
Rate for Payer: Monida Allegiance	$621.30
Rate for Payer: Monida First Choice Health	$634.38
Rate for Payer: Monida Montana Health Co-op	$621.30
Rate for Payer: Monida PacificSource	$621.30

PRO FEE OP INJ SUPRASCAP NERVE 764418

Professional

Both

$284.00

Service Code	HCPCS 64418
Hospital Charge Code	764418
Hospital Revenue Code	964
Min. Negotiated Rate	$198.80
Max. Negotiated Rate	$284.00
Rate for Payer: Aetna Commercial	$269.80
Rate for Payer: Aetna Medicare	$255.60
Rate for Payer: BCBS MT CHIP	$255.60
Rate for Payer: BCBS MT Closed Plan Network	$269.80
Rate for Payer: BCBS MT HealthLink	$255.60
Rate for Payer: BCBS MT Medicare	$255.60
Rate for Payer: BCBS MT POS	$269.80
Rate for Payer: BCBS MT Traditional	$284.00
Rate for Payer: Cash Price	$255.60
Rate for Payer: Cigna Commercial	$269.80
Rate for Payer: Cigna Medicare	$255.60
Rate for Payer: Medicaid All Medicaid	$261.28
Rate for Payer: Medicare All Medicare	$198.80
Rate for Payer: Monida Allegiance	$269.80
Rate for Payer: Monida First Choice Health	$275.48
Rate for Payer: Monida Montana Health Co-op	$269.80
Rate for Payer: Monida PacificSource	$269.80

PRO FEE OP INJ TRANFOR C/T ADDTL 64480

Professional

Both

$316.00

Service Code	HCPCS 64480
Hospital Charge Code	764480
Hospital Revenue Code	964
Min. Negotiated Rate	$221.20
Max. Negotiated Rate	$316.00
Rate for Payer: Aetna Commercial	$300.20
Rate for Payer: Aetna Medicare	$284.40
Rate for Payer: BCBS MT CHIP	$284.40
Rate for Payer: BCBS MT Closed Plan Network	$300.20
Rate for Payer: BCBS MT HealthLink	$284.40
Rate for Payer: BCBS MT Medicare	$284.40
Rate for Payer: BCBS MT POS	$300.20
Rate for Payer: BCBS MT Traditional	$316.00
Rate for Payer: Cash Price	$284.40
Rate for Payer: Cigna Commercial	$300.20
Rate for Payer: Cigna Medicare	$284.40
Rate for Payer: Medicaid All Medicaid	$290.72
Rate for Payer: Medicare All Medicare	$221.20
Rate for Payer: Monida Allegiance	$300.20
Rate for Payer: Monida First Choice Health	$306.52
Rate for Payer: Monida Montana Health Co-op	$300.20
Rate for Payer: Monida PacificSource	$300.20

PRO FEE OP INJ TRANSFORA L/S 1 64483

Professional

Both

$573.00

Service Code	HCPCS 64483
Hospital Charge Code	764483
Hospital Revenue Code	964
Min. Negotiated Rate	$401.10
Max. Negotiated Rate	$573.00
Rate for Payer: Aetna Commercial	$544.35
Rate for Payer: Aetna Medicare	$515.70
Rate for Payer: BCBS MT CHIP	$515.70
Rate for Payer: BCBS MT Closed Plan Network	$544.35
Rate for Payer: BCBS MT HealthLink	$515.70
Rate for Payer: BCBS MT Medicare	$515.70
Rate for Payer: BCBS MT POS	$544.35
Rate for Payer: BCBS MT Traditional	$573.00
Rate for Payer: Cash Price	$515.70
Rate for Payer: Cigna Commercial	$544.35
Rate for Payer: Cigna Medicare	$515.70
Rate for Payer: Medicaid All Medicaid	$527.16
Rate for Payer: Medicare All Medicare	$401.10
Rate for Payer: Monida Allegiance	$544.35
Rate for Payer: Monida First Choice Health	$555.81
Rate for Payer: Monida Montana Health Co-op	$544.35
Rate for Payer: Monida PacificSource	$544.35

PRO FEE OP INSERTION PICC LINE 36569

Professional

Both

$457.00

Service Code	HCPCS 36569
Hospital Charge Code	736569
Hospital Revenue Code	964
Min. Negotiated Rate	$319.90
Max. Negotiated Rate	$457.00
Rate for Payer: Aetna Commercial	$434.15
Rate for Payer: Aetna Medicare	$411.30
Rate for Payer: BCBS MT CHIP	$411.30
Rate for Payer: BCBS MT Closed Plan Network	$434.15
Rate for Payer: BCBS MT HealthLink	$411.30
Rate for Payer: BCBS MT Medicare	$411.30
Rate for Payer: BCBS MT POS	$434.15
Rate for Payer: BCBS MT Traditional	$457.00
Rate for Payer: Cash Price	$411.30
Rate for Payer: Cigna Commercial	$434.15
Rate for Payer: Cigna Medicare	$411.30
Rate for Payer: Medicaid All Medicaid	$420.44
Rate for Payer: Medicare All Medicare	$319.90
Rate for Payer: Monida Allegiance	$434.15
Rate for Payer: Monida First Choice Health	$443.29
Rate for Payer: Monida Montana Health Co-op	$434.15
Rate for Payer: Monida PacificSource	$434.15

PRO FEE OP MAJOR JOINT INJ W/US 20611

Professional

Both

$304.00

Service Code	HCPCS 20611 GF
Hospital Charge Code	720611
Hospital Revenue Code	964
Min. Negotiated Rate	$212.80
Max. Negotiated Rate	$304.00
Rate for Payer: Aetna Commercial	$288.80
Rate for Payer: Aetna Medicare	$273.60
Rate for Payer: BCBS MT CHIP	$273.60
Rate for Payer: BCBS MT Closed Plan Network	$288.80
Rate for Payer: BCBS MT HealthLink	$273.60
Rate for Payer: BCBS MT Medicare	$273.60
Rate for Payer: BCBS MT POS	$288.80
Rate for Payer: BCBS MT Traditional	$304.00
Rate for Payer: Cash Price	$273.60
Rate for Payer: Cigna Commercial	$288.80
Rate for Payer: Cigna Medicare	$273.60
Rate for Payer: Medicaid All Medicaid	$279.68
Rate for Payer: Medicare All Medicare	$212.80
Rate for Payer: Monida Allegiance	$288.80
Rate for Payer: Monida First Choice Health	$294.88
Rate for Payer: Monida Montana Health Co-op	$288.80
Rate for Payer: Monida PacificSource	$288.80

PRO FEE OPO HIGH

Professional

Both

$483.00

Service Code	HCPCS 99223 AQ
Hospital Charge Code	799220
Hospital Revenue Code	982
Min. Negotiated Rate	$338.10
Max. Negotiated Rate	$468.51
Rate for Payer: Aetna Commercial	$458.85
Rate for Payer: Aetna Medicare	$434.70
Rate for Payer: Cash Price	$434.70
Rate for Payer: Medicaid All Medicaid	$444.36
Rate for Payer: Medicare All Medicare	$338.10
Rate for Payer: Monida Allegiance	$458.85
Rate for Payer: Monida First Choice Health	$468.51
Rate for Payer: Monida Montana Health Co-op	$458.85
Rate for Payer: Monida PacificSource	$458.85

PRO FEE OPO LOW (99221)

Professional

Both

$230.00

Service Code	HCPCS 99221 AQ
Hospital Charge Code	799218
Hospital Revenue Code	982
Min. Negotiated Rate	$161.00
Max. Negotiated Rate	$223.10
Rate for Payer: Aetna Commercial	$218.50
Rate for Payer: Aetna Medicare	$207.00
Rate for Payer: Cash Price	$207.00
Rate for Payer: Medicaid All Medicaid	$211.60
Rate for Payer: Medicare All Medicare	$161.00
Rate for Payer: Monida Allegiance	$218.50
Rate for Payer: Monida First Choice Health	$223.10
Rate for Payer: Monida Montana Health Co-op	$218.50
Rate for Payer: Monida PacificSource	$218.50

PRO FEE OPO MODERATE

Professional

Both

$363.00

Service Code	HCPCS 99222 AQ
Hospital Charge Code	799219
Hospital Revenue Code	982
Min. Negotiated Rate	$254.10
Max. Negotiated Rate	$352.11
Rate for Payer: Aetna Commercial	$344.85
Rate for Payer: Aetna Medicare	$326.70
Rate for Payer: Cash Price	$326.70
Rate for Payer: Medicaid All Medicaid	$333.96
Rate for Payer: Medicare All Medicare	$254.10
Rate for Payer: Monida Allegiance	$344.85
Rate for Payer: Monida First Choice Health	$352.11
Rate for Payer: Monida Montana Health Co-op	$344.85
Rate for Payer: Monida PacificSource	$344.85

PRO FEE OPO SAME DAY ADMIT/D/CLOW

Professional

Both

$278.00

Service Code	HCPCS 99234 AQ
Hospital Charge Code	739234
Hospital Revenue Code	982
Min. Negotiated Rate	$194.60
Max. Negotiated Rate	$269.66
Rate for Payer: Aetna Commercial	$264.10
Rate for Payer: Aetna Medicare	$250.20
Rate for Payer: Cash Price	$250.20
Rate for Payer: Medicaid All Medicaid	$255.76
Rate for Payer: Medicare All Medicare	$194.60
Rate for Payer: Monida Allegiance	$264.10
Rate for Payer: Monida First Choice Health	$269.66
Rate for Payer: Monida Montana Health Co-op	$264.10
Rate for Payer: Monida PacificSource	$264.10

PRO FEE OPO SAME DAY ADMIT HIGH

Professional

Both

$457.00

Service Code	HCPCS 99236 AQ
Hospital Charge Code	799236
Hospital Revenue Code	982
Min. Negotiated Rate	$319.90
Max. Negotiated Rate	$443.29
Rate for Payer: Aetna Commercial	$434.15
Rate for Payer: Aetna Medicare	$411.30
Rate for Payer: Cash Price	$411.30
Rate for Payer: Medicaid All Medicaid	$420.44
Rate for Payer: Medicare All Medicare	$319.90
Rate for Payer: Monida Allegiance	$434.15
Rate for Payer: Monida First Choice Health	$443.29
Rate for Payer: Monida Montana Health Co-op	$434.15
Rate for Payer: Monida PacificSource	$434.15

PRO FEE OPO SAME DAY ADMIT MOD

Professional

Both

$352.00

Service Code	HCPCS 99235 AQ
Hospital Charge Code	739235
Hospital Revenue Code	982
Min. Negotiated Rate	$246.40
Max. Negotiated Rate	$341.44
Rate for Payer: Aetna Commercial	$334.40
Rate for Payer: Aetna Medicare	$316.80
Rate for Payer: Cash Price	$316.80
Rate for Payer: Medicaid All Medicaid	$323.84
Rate for Payer: Medicare All Medicare	$246.40
Rate for Payer: Monida Allegiance	$334.40
Rate for Payer: Monida First Choice Health	$341.44
Rate for Payer: Monida Montana Health Co-op	$334.40
Rate for Payer: Monida PacificSource	$334.40

PRO FEE OPO SEPARATE DAY DISCHARGE 30MI

Professional

Both

$227.00

Service Code	HCPCS 99238 AQ
Hospital Charge Code	799238
Hospital Revenue Code	982
Min. Negotiated Rate	$158.90
Max. Negotiated Rate	$220.19
Rate for Payer: Aetna Commercial	$215.65
Rate for Payer: Aetna Medicare	$204.30
Rate for Payer: Cash Price	$204.30
Rate for Payer: Medicaid All Medicaid	$208.84
Rate for Payer: Medicare All Medicare	$158.90
Rate for Payer: Monida Allegiance	$215.65
Rate for Payer: Monida First Choice Health	$220.19
Rate for Payer: Monida Montana Health Co-op	$215.65
Rate for Payer: Monida PacificSource	$215.65

PRO FEE OPO SEPARATE DAY DISCHARGE>30MI

Professional

Both

$320.00

Service Code	HCPCS 99239 AQ
Hospital Charge Code	799239
Hospital Revenue Code	982
Min. Negotiated Rate	$224.00
Max. Negotiated Rate	$310.40
Rate for Payer: Aetna Commercial	$304.00
Rate for Payer: Aetna Medicare	$288.00
Rate for Payer: Cash Price	$288.00
Rate for Payer: Medicaid All Medicaid	$294.40
Rate for Payer: Medicare All Medicare	$224.00
Rate for Payer: Monida Allegiance	$304.00
Rate for Payer: Monida First Choice Health	$310.40
Rate for Payer: Monida Montana Health Co-op	$304.00
Rate for Payer: Monida PacificSource	$304.00

PRO FEE OPO SEPARATE DAY DISCHARGE 99217

Professional

Both

$189.00

Service Code	HCPCS 99217 AQ
Hospital Charge Code	799217
Hospital Revenue Code	982
Min. Negotiated Rate	$132.30
Max. Negotiated Rate	$183.33
Rate for Payer: Aetna Commercial	$179.55
Rate for Payer: Aetna Medicare	$170.10
Rate for Payer: Cash Price	$170.10
Rate for Payer: Medicaid All Medicaid	$173.88
Rate for Payer: Medicare All Medicare	$132.30
Rate for Payer: Monida Allegiance	$179.55
Rate for Payer: Monida First Choice Health	$183.33
Rate for Payer: Monida Montana Health Co-op	$179.55
Rate for Payer: Monida PacificSource	$179.55

PRO FEE OP PMGT INJ TRIGEM NRV BLC 64400

Professional

Both

$271.00

Service Code	HCPCS 64400
Hospital Charge Code	764400
Hospital Revenue Code	964
Min. Negotiated Rate	$189.70
Max. Negotiated Rate	$271.00
Rate for Payer: Aetna Commercial	$257.45
Rate for Payer: Aetna Medicare	$243.90
Rate for Payer: BCBS MT CHIP	$243.90
Rate for Payer: BCBS MT Closed Plan Network	$257.45
Rate for Payer: BCBS MT HealthLink	$243.90
Rate for Payer: BCBS MT Medicare	$243.90
Rate for Payer: BCBS MT POS	$257.45
Rate for Payer: BCBS MT Traditional	$271.00
Rate for Payer: Cash Price	$243.90
Rate for Payer: Cigna Commercial	$257.45
Rate for Payer: Cigna Medicare	$243.90
Rate for Payer: Medicaid All Medicaid	$249.32
Rate for Payer: Medicare All Medicare	$189.70
Rate for Payer: Monida Allegiance	$257.45
Rate for Payer: Monida First Choice Health	$262.87
Rate for Payer: Monida Montana Health Co-op	$257.45
Rate for Payer: Monida PacificSource	$257.45

PRO FEE OP UNLISTED PROCEDURE 64999

Professional

Both

$449.00

Service Code	HCPCS 64999
Hospital Charge Code	764999
Hospital Revenue Code	964
Min. Negotiated Rate	$314.30
Max. Negotiated Rate	$449.00
Rate for Payer: Aetna Commercial	$426.55
Rate for Payer: Aetna Medicare	$404.10
Rate for Payer: BCBS MT CHIP	$404.10
Rate for Payer: BCBS MT Closed Plan Network	$426.55
Rate for Payer: BCBS MT HealthLink	$404.10
Rate for Payer: BCBS MT Medicare	$404.10
Rate for Payer: BCBS MT POS	$426.55
Rate for Payer: BCBS MT Traditional	$449.00
Rate for Payer: Cash Price	$404.10
Rate for Payer: Cigna Commercial	$426.55
Rate for Payer: Cigna Medicare	$404.10
Rate for Payer: Medicaid All Medicaid	$413.08
Rate for Payer: Medicare All Medicare	$314.30
Rate for Payer: Monida Allegiance	$426.55
Rate for Payer: Monida First Choice Health	$435.53
Rate for Payer: Monida Montana Health Co-op	$426.55
Rate for Payer: Monida PacificSource	$426.55

PRO FEE PARAVERT SYMP BLOCK T/L 64520

Professional

Both

$439.00

Service Code	HCPCS 64520
Hospital Charge Code	764520
Hospital Revenue Code	964
Min. Negotiated Rate	$307.30
Max. Negotiated Rate	$439.00
Rate for Payer: Aetna Commercial	$417.05
Rate for Payer: Aetna Medicare	$395.10
Rate for Payer: BCBS MT CHIP	$395.10
Rate for Payer: BCBS MT Closed Plan Network	$417.05
Rate for Payer: BCBS MT HealthLink	$395.10
Rate for Payer: BCBS MT Medicare	$395.10
Rate for Payer: BCBS MT POS	$417.05
Rate for Payer: BCBS MT Traditional	$439.00
Rate for Payer: Cash Price	$395.10
Rate for Payer: Cigna Commercial	$417.05
Rate for Payer: Cigna Medicare	$395.10
Rate for Payer: Medicaid All Medicaid	$403.88
Rate for Payer: Medicare All Medicare	$307.30
Rate for Payer: Monida Allegiance	$417.05
Rate for Payer: Monida First Choice Health	$425.83
Rate for Payer: Monida Montana Health Co-op	$417.05
Rate for Payer: Monida PacificSource	$417.05

PRO FEE PLEURAL DRNG, PERC,W/INS OF CATH

Professional

Both

$122.00

Service Code	HCPCS 32556 AQ
Hospital Charge Code	732556
Hospital Revenue Code	981
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

PRO FEE PVB THORACIC 1ST LEVEL

Professional

Both

$394.00

Service Code	HCPCS 64461
Hospital Charge Code	764461
Hospital Revenue Code	964
Min. Negotiated Rate	$275.80
Max. Negotiated Rate	$394.00
Rate for Payer: Aetna Commercial	$374.30
Rate for Payer: Aetna Medicare	$354.60
Rate for Payer: BCBS MT CHIP	$354.60
Rate for Payer: BCBS MT Closed Plan Network	$374.30
Rate for Payer: BCBS MT HealthLink	$354.60
Rate for Payer: BCBS MT Medicare	$354.60
Rate for Payer: BCBS MT POS	$374.30
Rate for Payer: BCBS MT Traditional	$394.00
Rate for Payer: Cash Price	$354.60
Rate for Payer: Cigna Commercial	$374.30
Rate for Payer: Cigna Medicare	$354.60
Rate for Payer: Medicaid All Medicaid	$362.48
Rate for Payer: Medicare All Medicare	$275.80
Rate for Payer: Monida Allegiance	$374.30
Rate for Payer: Monida First Choice Health	$382.18
Rate for Payer: Monida Montana Health Co-op	$374.30
Rate for Payer: Monida PacificSource	$374.30

PRO FEE PVB THORACIC ADD ON LEVEL

Professional

Both

$244.00

Service Code	HCPCS 64462
Hospital Charge Code	764462
Hospital Revenue Code	964
Min. Negotiated Rate	$170.80
Max. Negotiated Rate	$244.00
Rate for Payer: Aetna Commercial	$231.80
Rate for Payer: Aetna Medicare	$219.60
Rate for Payer: BCBS MT CHIP	$219.60
Rate for Payer: BCBS MT Closed Plan Network	$231.80
Rate for Payer: BCBS MT HealthLink	$219.60
Rate for Payer: BCBS MT Medicare	$219.60
Rate for Payer: BCBS MT POS	$231.80
Rate for Payer: BCBS MT Traditional	$244.00
Rate for Payer: Cash Price	$219.60
Rate for Payer: Cigna Commercial	$231.80
Rate for Payer: Cigna Medicare	$219.60
Rate for Payer: Medicaid All Medicaid	$224.48
Rate for Payer: Medicare All Medicare	$170.80
Rate for Payer: Monida Allegiance	$231.80
Rate for Payer: Monida First Choice Health	$236.68
Rate for Payer: Monida Montana Health Co-op	$231.80
Rate for Payer: Monida PacificSource	$231.80

PRO FEE REDUCTION DISTAL FRACTURE RAD

Professional

Both

$2,497.00

Service Code	HCPCS 25505
Hospital Charge Code	782505
Hospital Revenue Code	964
Min. Negotiated Rate	$1,747.90
Max. Negotiated Rate	$2,497.00
Rate for Payer: Aetna Commercial	$2,372.15
Rate for Payer: Aetna Medicare	$2,247.30
Rate for Payer: BCBS MT CHIP	$2,247.30
Rate for Payer: BCBS MT Closed Plan Network	$2,372.15
Rate for Payer: BCBS MT HealthLink	$2,247.30
Rate for Payer: BCBS MT Medicare	$2,247.30
Rate for Payer: BCBS MT POS	$2,372.15
Rate for Payer: BCBS MT Traditional	$2,497.00
Rate for Payer: Cash Price	$2,247.30
Rate for Payer: Cigna Commercial	$2,372.15
Rate for Payer: Cigna Medicare	$2,247.30
Rate for Payer: Medicaid All Medicaid	$2,297.24
Rate for Payer: Medicare All Medicare	$1,747.90
Rate for Payer: Monida Allegiance	$2,372.15
Rate for Payer: Monida First Choice Health	$2,422.09
Rate for Payer: Monida Montana Health Co-op	$2,372.15
Rate for Payer: Monida PacificSource	$2,372.15

Know your out-of-pocket cost for care.

All Charges