Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

OP INJ SUPRASCAPULAR NERVE 64418

Facility

$848.00

Service Code	CPT 64418
Hospital Charge Code	1564418
Hospital Revenue Code	761
Min. Negotiated Rate	$593.60
Max. Negotiated Rate	$848.00
Rate for Payer: Aetna Commercial	$805.60
Rate for Payer: Aetna Medicare	$763.20
Rate for Payer: BCBS MT CHIP	$763.20
Rate for Payer: BCBS MT Closed Plan Network	$805.60
Rate for Payer: BCBS MT HealthLink	$763.20
Rate for Payer: BCBS MT Medicare	$763.20
Rate for Payer: BCBS MT POS	$805.60
Rate for Payer: BCBS MT Traditional	$848.00
Rate for Payer: Cash Price	$763.20
Rate for Payer: Cigna Commercial	$805.60
Rate for Payer: Cigna Medicare	$763.20
Rate for Payer: Medicaid All Medicaid	$780.16
Rate for Payer: Medicare All Medicare	$593.60
Rate for Payer: Monida Allegiance	$805.60
Rate for Payer: Monida First Choice Health	$822.56
Rate for Payer: Monida Montana Health Co-op	$805.60
Rate for Payer: Monida PacificSource	$805.60

OP INJ SUPRASCAPULAR NERVE 64418

Facility

$848.00

Service Code	CPT 64418
Hospital Charge Code	1564418
Hospital Revenue Code	761
Min. Negotiated Rate	$593.60
Max. Negotiated Rate	$848.00
Rate for Payer: Aetna Commercial	$805.60
Rate for Payer: Aetna Medicare	$763.20
Rate for Payer: BCBS MT CHIP	$763.20
Rate for Payer: BCBS MT Closed Plan Network	$805.60
Rate for Payer: BCBS MT HealthLink	$763.20
Rate for Payer: BCBS MT Medicare	$763.20
Rate for Payer: BCBS MT POS	$805.60
Rate for Payer: BCBS MT Traditional	$848.00
Rate for Payer: Cash Price	$763.20
Rate for Payer: Cigna Commercial	$805.60
Rate for Payer: Cigna Medicare	$763.20
Rate for Payer: Medicaid All Medicaid	$780.16
Rate for Payer: Medicare All Medicare	$593.60
Rate for Payer: Monida Allegiance	$805.60
Rate for Payer: Monida First Choice Health	$822.56
Rate for Payer: Monida Montana Health Co-op	$805.60
Rate for Payer: Monida PacificSource	$805.60

OP INJ TRANSFOR C/T 1ST 64479

Facility

$1,732.00

Service Code	CPT 64479
Hospital Charge Code	1564479
Hospital Revenue Code	761
Min. Negotiated Rate	$1,212.40
Max. Negotiated Rate	$1,732.00
Rate for Payer: Aetna Commercial	$1,645.40
Rate for Payer: Aetna Medicare	$1,558.80
Rate for Payer: BCBS MT CHIP	$1,558.80
Rate for Payer: BCBS MT Closed Plan Network	$1,645.40
Rate for Payer: BCBS MT HealthLink	$1,558.80
Rate for Payer: BCBS MT Medicare	$1,558.80
Rate for Payer: BCBS MT POS	$1,645.40
Rate for Payer: BCBS MT Traditional	$1,732.00
Rate for Payer: Cash Price	$1,558.80
Rate for Payer: Cigna Commercial	$1,645.40
Rate for Payer: Cigna Medicare	$1,558.80
Rate for Payer: Medicaid All Medicaid	$1,593.44
Rate for Payer: Medicare All Medicare	$1,212.40
Rate for Payer: Monida Allegiance	$1,645.40
Rate for Payer: Monida First Choice Health	$1,680.04
Rate for Payer: Monida Montana Health Co-op	$1,645.40
Rate for Payer: Monida PacificSource	$1,645.40

OP INJ TRANSFOR C/T 1ST 64479

Facility

$1,732.00

Service Code	CPT 64479
Hospital Charge Code	1564479
Hospital Revenue Code	761
Min. Negotiated Rate	$1,212.40
Max. Negotiated Rate	$1,732.00
Rate for Payer: Aetna Commercial	$1,645.40
Rate for Payer: Aetna Medicare	$1,558.80
Rate for Payer: BCBS MT CHIP	$1,558.80
Rate for Payer: BCBS MT Closed Plan Network	$1,645.40
Rate for Payer: BCBS MT HealthLink	$1,558.80
Rate for Payer: BCBS MT Medicare	$1,558.80
Rate for Payer: BCBS MT POS	$1,645.40
Rate for Payer: BCBS MT Traditional	$1,732.00
Rate for Payer: Cash Price	$1,558.80
Rate for Payer: Cigna Commercial	$1,645.40
Rate for Payer: Cigna Medicare	$1,558.80
Rate for Payer: Medicaid All Medicaid	$1,593.44
Rate for Payer: Medicare All Medicare	$1,212.40
Rate for Payer: Monida Allegiance	$1,645.40
Rate for Payer: Monida First Choice Health	$1,680.04
Rate for Payer: Monida Montana Health Co-op	$1,645.40
Rate for Payer: Monida PacificSource	$1,645.40

OP INJ TRANSFOR L/S ADD 64484

Facility

$840.00

Service Code	CPT 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	CPT 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

$695.00

Service Code	CPT 64454
Hospital Charge Code	1564454
Hospital Revenue Code	761
Min. Negotiated Rate	$486.50
Max. Negotiated Rate	$695.00
Rate for Payer: Aetna Commercial	$660.25
Rate for Payer: Aetna Medicare	$625.50
Rate for Payer: BCBS MT CHIP	$625.50
Rate for Payer: BCBS MT Closed Plan Network	$660.25
Rate for Payer: BCBS MT HealthLink	$625.50
Rate for Payer: BCBS MT Medicare	$625.50
Rate for Payer: BCBS MT POS	$660.25
Rate for Payer: BCBS MT Traditional	$695.00
Rate for Payer: Cash Price	$625.50
Rate for Payer: Cigna Commercial	$660.25
Rate for Payer: Cigna Medicare	$625.50
Rate for Payer: Medicaid All Medicaid	$639.40
Rate for Payer: Medicare All Medicare	$486.50
Rate for Payer: Monida Allegiance	$660.25
Rate for Payer: Monida First Choice Health	$674.15
Rate for Payer: Monida Montana Health Co-op	$660.25
Rate for Payer: Monida PacificSource	$660.25

OP INTO/INJ GENICULAR NERVE BRANCH 64454

Facility

$695.00

Service Code	CPT 64454
Hospital Charge Code	1564454
Hospital Revenue Code	761
Min. Negotiated Rate	$486.50
Max. Negotiated Rate	$695.00
Rate for Payer: Aetna Commercial	$660.25
Rate for Payer: Aetna Medicare	$625.50
Rate for Payer: BCBS MT CHIP	$625.50
Rate for Payer: BCBS MT Closed Plan Network	$660.25
Rate for Payer: BCBS MT HealthLink	$625.50
Rate for Payer: BCBS MT Medicare	$625.50
Rate for Payer: BCBS MT POS	$660.25
Rate for Payer: BCBS MT Traditional	$695.00
Rate for Payer: Cash Price	$625.50
Rate for Payer: Cigna Commercial	$660.25
Rate for Payer: Cigna Medicare	$625.50
Rate for Payer: Medicaid All Medicaid	$639.40
Rate for Payer: Medicare All Medicare	$486.50
Rate for Payer: Monida Allegiance	$660.25
Rate for Payer: Monida First Choice Health	$674.15
Rate for Payer: Monida Montana Health Co-op	$660.25
Rate for Payer: Monida PacificSource	$660.25

OP MAJOR JOINT INJ W/O US 20610

Facility

$984.00

Service Code	CPT 20610
Hospital Charge Code	520610
Hospital Revenue Code	761
Min. Negotiated Rate	$688.80
Max. Negotiated Rate	$984.00
Rate for Payer: Aetna Commercial	$934.80
Rate for Payer: Aetna Medicare	$885.60
Rate for Payer: BCBS MT CHIP	$885.60
Rate for Payer: BCBS MT Closed Plan Network	$934.80
Rate for Payer: BCBS MT HealthLink	$885.60
Rate for Payer: BCBS MT Medicare	$885.60
Rate for Payer: BCBS MT POS	$934.80
Rate for Payer: BCBS MT Traditional	$984.00
Rate for Payer: Cash Price	$885.60
Rate for Payer: Cigna Commercial	$934.80
Rate for Payer: Cigna Medicare	$885.60
Rate for Payer: Medicaid All Medicaid	$905.28
Rate for Payer: Medicare All Medicare	$688.80
Rate for Payer: Monida Allegiance	$934.80
Rate for Payer: Monida First Choice Health	$954.48
Rate for Payer: Monida Montana Health Co-op	$934.80
Rate for Payer: Monida PacificSource	$934.80

OP MAJOR JOINT INJ W/O US 20610

Facility

$984.00

Service Code	CPT 20610
Hospital Charge Code	520610
Hospital Revenue Code	761
Min. Negotiated Rate	$688.80
Max. Negotiated Rate	$984.00
Rate for Payer: Aetna Commercial	$934.80
Rate for Payer: Aetna Medicare	$885.60
Rate for Payer: BCBS MT CHIP	$885.60
Rate for Payer: BCBS MT Closed Plan Network	$934.80
Rate for Payer: BCBS MT HealthLink	$885.60
Rate for Payer: BCBS MT Medicare	$885.60
Rate for Payer: BCBS MT POS	$934.80
Rate for Payer: BCBS MT Traditional	$984.00
Rate for Payer: Cash Price	$885.60
Rate for Payer: Cigna Commercial	$934.80
Rate for Payer: Cigna Medicare	$885.60
Rate for Payer: Medicaid All Medicaid	$905.28
Rate for Payer: Medicare All Medicare	$688.80
Rate for Payer: Monida Allegiance	$934.80
Rate for Payer: Monida First Choice Health	$954.48
Rate for Payer: Monida Montana Health Co-op	$934.80
Rate for Payer: Monida PacificSource	$934.80

OP MOD CON SEDATION ADDTL 15 MIN 99153

Facility

$129.00

Service Code	CPT 99153
Hospital Charge Code	1599153
Hospital Revenue Code	370
Min. Negotiated Rate	$90.30
Max. Negotiated Rate	$129.00
Rate for Payer: Aetna Commercial	$122.55
Rate for Payer: Aetna Medicare	$116.10
Rate for Payer: BCBS MT CHIP	$116.10
Rate for Payer: BCBS MT Closed Plan Network	$122.55
Rate for Payer: BCBS MT HealthLink	$116.10
Rate for Payer: BCBS MT Medicare	$116.10
Rate for Payer: BCBS MT POS	$122.55
Rate for Payer: BCBS MT Traditional	$129.00
Rate for Payer: Cash Price	$116.10
Rate for Payer: Cigna Commercial	$122.55
Rate for Payer: Cigna Medicare	$116.10
Rate for Payer: Medicaid All Medicaid	$118.68
Rate for Payer: Medicare All Medicare	$90.30
Rate for Payer: Monida Allegiance	$122.55
Rate for Payer: Monida First Choice Health	$125.13
Rate for Payer: Monida Montana Health Co-op	$122.55
Rate for Payer: Monida PacificSource	$122.55

OP MOD CON SEDATION ADDTL 15 MIN 99153

Facility

$129.00

Service Code	CPT 99153
Hospital Charge Code	1599153
Hospital Revenue Code	370
Min. Negotiated Rate	$90.30
Max. Negotiated Rate	$129.00
Rate for Payer: Aetna Commercial	$122.55
Rate for Payer: Aetna Medicare	$116.10
Rate for Payer: BCBS MT CHIP	$116.10
Rate for Payer: BCBS MT Closed Plan Network	$122.55
Rate for Payer: BCBS MT HealthLink	$116.10
Rate for Payer: BCBS MT Medicare	$116.10
Rate for Payer: BCBS MT POS	$122.55
Rate for Payer: BCBS MT Traditional	$129.00
Rate for Payer: Cash Price	$116.10
Rate for Payer: Cigna Commercial	$122.55
Rate for Payer: Cigna Medicare	$116.10
Rate for Payer: Medicaid All Medicaid	$118.68
Rate for Payer: Medicare All Medicare	$90.30
Rate for Payer: Monida Allegiance	$122.55
Rate for Payer: Monida First Choice Health	$125.13
Rate for Payer: Monida Montana Health Co-op	$122.55
Rate for Payer: Monida PacificSource	$122.55

OPO DIRECT ADMISSION

Facility

$197.00

Service Code	HCPCS G0379
Hospital Charge Code	210053
Hospital Revenue Code	762
Min. Negotiated Rate	$137.90
Max. Negotiated Rate	$197.00
Rate for Payer: Aetna Commercial	$187.15
Rate for Payer: Aetna Medicare	$177.30
Rate for Payer: BCBS MT CHIP	$177.30
Rate for Payer: BCBS MT Closed Plan Network	$187.15
Rate for Payer: BCBS MT HealthLink	$177.30
Rate for Payer: BCBS MT Medicare	$177.30
Rate for Payer: BCBS MT POS	$187.15
Rate for Payer: BCBS MT Traditional	$197.00
Rate for Payer: Cash Price	$177.30
Rate for Payer: Cigna Commercial	$187.15
Rate for Payer: Cigna Medicare	$177.30
Rate for Payer: Medicaid All Medicaid	$181.24
Rate for Payer: Medicare All Medicare	$137.90
Rate for Payer: Monida Allegiance	$187.15
Rate for Payer: Monida First Choice Health	$191.09
Rate for Payer: Monida Montana Health Co-op	$187.15
Rate for Payer: Monida PacificSource	$187.15

OPO DIRECT ADMISSION

Facility

$197.00

Service Code	HCPCS G0379
Hospital Charge Code	210053
Hospital Revenue Code	762
Min. Negotiated Rate	$137.90
Max. Negotiated Rate	$197.00
Rate for Payer: Aetna Commercial	$187.15
Rate for Payer: Aetna Medicare	$177.30
Rate for Payer: BCBS MT CHIP	$177.30
Rate for Payer: BCBS MT Closed Plan Network	$187.15
Rate for Payer: BCBS MT HealthLink	$177.30
Rate for Payer: BCBS MT Medicare	$177.30
Rate for Payer: BCBS MT POS	$187.15
Rate for Payer: BCBS MT Traditional	$197.00
Rate for Payer: Cash Price	$177.30
Rate for Payer: Cigna Commercial	$187.15
Rate for Payer: Cigna Medicare	$177.30
Rate for Payer: Medicaid All Medicaid	$181.24
Rate for Payer: Medicare All Medicare	$137.90
Rate for Payer: Monida Allegiance	$187.15
Rate for Payer: Monida First Choice Health	$191.09
Rate for Payer: Monida Montana Health Co-op	$187.15
Rate for Payer: Monida PacificSource	$187.15

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

$52.00

Service Code	HCPCS G0378
Hospital Charge Code	210052
Hospital Revenue Code	762
Min. Negotiated Rate	$36.40
Max. Negotiated Rate	$52.00
Rate for Payer: Aetna Commercial	$49.40
Rate for Payer: Aetna Medicare	$46.80
Rate for Payer: BCBS MT CHIP	$46.80
Rate for Payer: BCBS MT Closed Plan Network	$49.40
Rate for Payer: BCBS MT HealthLink	$46.80
Rate for Payer: BCBS MT Medicare	$46.80
Rate for Payer: BCBS MT POS	$49.40
Rate for Payer: BCBS MT Traditional	$52.00
Rate for Payer: Cash Price	$46.80
Rate for Payer: Cigna Commercial	$49.40
Rate for Payer: Cigna Medicare	$46.80
Rate for Payer: Medicaid All Medicaid	$47.84
Rate for Payer: Medicare All Medicare	$36.40
Rate for Payer: Monida Allegiance	$49.40
Rate for Payer: Monida First Choice Health	$50.44
Rate for Payer: Monida Montana Health Co-op	$49.40
Rate for Payer: Monida PacificSource	$49.40

OPO PER HOUR 2 OR MORE

Facility

$52.00

Service Code	HCPCS G0378
Hospital Charge Code	210052
Hospital Revenue Code	762
Min. Negotiated Rate	$36.40
Max. Negotiated Rate	$52.00
Rate for Payer: Aetna Commercial	$49.40
Rate for Payer: Aetna Medicare	$46.80
Rate for Payer: BCBS MT CHIP	$46.80
Rate for Payer: BCBS MT Closed Plan Network	$49.40
Rate for Payer: BCBS MT HealthLink	$46.80
Rate for Payer: BCBS MT Medicare	$46.80
Rate for Payer: BCBS MT POS	$49.40
Rate for Payer: BCBS MT Traditional	$52.00
Rate for Payer: Cash Price	$46.80
Rate for Payer: Cigna Commercial	$49.40
Rate for Payer: Cigna Medicare	$46.80
Rate for Payer: Medicaid All Medicaid	$47.84
Rate for Payer: Medicare All Medicare	$36.40
Rate for Payer: Monida Allegiance	$49.40
Rate for Payer: Monida First Choice Health	$50.44
Rate for Payer: Monida Montana Health Co-op	$49.40
Rate for Payer: Monida PacificSource	$49.40

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

Facility

$312.00

Service Code	CPT 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	CPT 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

$331.00

Service Code	CPT 64417
Hospital Charge Code	764417
Hospital Revenue Code	964
Min. Negotiated Rate	$231.70
Max. Negotiated Rate	$331.00
Rate for Payer: Aetna Commercial	$314.45
Rate for Payer: Aetna Medicare	$297.90
Rate for Payer: BCBS MT CHIP	$297.90
Rate for Payer: BCBS MT Closed Plan Network	$314.45
Rate for Payer: BCBS MT HealthLink	$297.90
Rate for Payer: BCBS MT Medicare	$297.90
Rate for Payer: BCBS MT POS	$314.45
Rate for Payer: BCBS MT Traditional	$331.00
Rate for Payer: Cash Price	$297.90
Rate for Payer: Cigna Commercial	$314.45
Rate for Payer: Cigna Medicare	$297.90
Rate for Payer: Medicaid All Medicaid	$304.52
Rate for Payer: Medicare All Medicare	$231.70
Rate for Payer: Monida Allegiance	$314.45
Rate for Payer: Monida First Choice Health	$321.07
Rate for Payer: Monida Montana Health Co-op	$314.45
Rate for Payer: Monida PacificSource	$314.45

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

Know your out-of-pocket cost for care.

All Charges