Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

RAPID STREP TEST - RVMC

Facility

$49.00

Service Code	CPT 87430
Hospital Charge Code	8087430
Hospital Revenue Code	521
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

RAPID STREP TEST - TWIN BRIDGES

Facility

$49.00

Service Code	CPT 87430
Hospital Charge Code	8187430
Hospital Revenue Code	521
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

RAPID STREP TEST - TWIN BRIDGES

Facility

$49.00

Service Code	CPT 87430
Hospital Charge Code	8187430
Hospital Revenue Code	521
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

RED BLOOD CELL COUNT, BLOOD

Facility

$54.00

Service Code	CPT 85041
Hospital Charge Code	4085041
Hospital Revenue Code	305
Min. Negotiated Rate	$37.80
Max. Negotiated Rate	$54.00
Rate for Payer: Aetna Commercial	$51.30
Rate for Payer: Aetna Medicare	$48.60
Rate for Payer: BCBS MT CHIP	$48.60
Rate for Payer: BCBS MT Closed Plan Network	$51.30
Rate for Payer: BCBS MT HealthLink	$48.60
Rate for Payer: BCBS MT Medicare	$48.60
Rate for Payer: BCBS MT POS	$51.30
Rate for Payer: BCBS MT Traditional	$54.00
Rate for Payer: Cash Price	$48.60
Rate for Payer: Cigna Commercial	$51.30
Rate for Payer: Cigna Medicare	$48.60
Rate for Payer: Medicaid All Medicaid	$49.68
Rate for Payer: Medicare All Medicare	$37.80
Rate for Payer: Monida Allegiance	$51.30
Rate for Payer: Monida First Choice Health	$52.38
Rate for Payer: Monida Montana Health Co-op	$51.30
Rate for Payer: Monida PacificSource	$51.30

RED BLOOD CELL COUNT, BLOOD

Facility

$54.00

Service Code	CPT 85041
Hospital Charge Code	4085041
Hospital Revenue Code	305
Min. Negotiated Rate	$37.80
Max. Negotiated Rate	$54.00
Rate for Payer: Aetna Commercial	$51.30
Rate for Payer: Aetna Medicare	$48.60
Rate for Payer: BCBS MT CHIP	$48.60
Rate for Payer: BCBS MT Closed Plan Network	$51.30
Rate for Payer: BCBS MT HealthLink	$48.60
Rate for Payer: BCBS MT Medicare	$48.60
Rate for Payer: BCBS MT POS	$51.30
Rate for Payer: BCBS MT Traditional	$54.00
Rate for Payer: Cash Price	$48.60
Rate for Payer: Cigna Commercial	$51.30
Rate for Payer: Cigna Medicare	$48.60
Rate for Payer: Medicaid All Medicaid	$49.68
Rate for Payer: Medicare All Medicare	$37.80
Rate for Payer: Monida Allegiance	$51.30
Rate for Payer: Monida First Choice Health	$52.38
Rate for Payer: Monida Montana Health Co-op	$51.30
Rate for Payer: Monida PacificSource	$51.30

REMDESIVIR INJ [100 MG]

Facility

$918.00

Service Code	HCPCS J3490
Hospital Charge Code	3000414
Hospital Revenue Code	250
Min. Negotiated Rate	$642.60
Max. Negotiated Rate	$918.00
Rate for Payer: Aetna Commercial	$872.10
Rate for Payer: Aetna Medicare	$826.20
Rate for Payer: BCBS MT CHIP	$826.20
Rate for Payer: BCBS MT Closed Plan Network	$872.10
Rate for Payer: BCBS MT HealthLink	$826.20
Rate for Payer: BCBS MT Medicare	$826.20
Rate for Payer: BCBS MT POS	$872.10
Rate for Payer: BCBS MT Traditional	$918.00
Rate for Payer: Cash Price	$826.20
Rate for Payer: Cigna Commercial	$872.10
Rate for Payer: Cigna Medicare	$826.20
Rate for Payer: Medicaid All Medicaid	$844.56
Rate for Payer: Medicare All Medicare	$642.60
Rate for Payer: Monida Allegiance	$872.10
Rate for Payer: Monida First Choice Health	$890.46
Rate for Payer: Monida Montana Health Co-op	$872.10
Rate for Payer: Monida PacificSource	$872.10

REMDESIVIR INJ [100 MG]

Facility

$918.00

Service Code	HCPCS J3490
Hospital Charge Code	3000414
Hospital Revenue Code	250
Min. Negotiated Rate	$642.60
Max. Negotiated Rate	$918.00
Rate for Payer: Aetna Commercial	$872.10
Rate for Payer: Aetna Medicare	$826.20
Rate for Payer: BCBS MT CHIP	$826.20
Rate for Payer: BCBS MT Closed Plan Network	$872.10
Rate for Payer: BCBS MT HealthLink	$826.20
Rate for Payer: BCBS MT Medicare	$826.20
Rate for Payer: BCBS MT POS	$872.10
Rate for Payer: BCBS MT Traditional	$918.00
Rate for Payer: Cash Price	$826.20
Rate for Payer: Cigna Commercial	$872.10
Rate for Payer: Cigna Medicare	$826.20
Rate for Payer: Medicaid All Medicaid	$844.56
Rate for Payer: Medicare All Medicare	$642.60
Rate for Payer: Monida Allegiance	$872.10
Rate for Payer: Monida First Choice Health	$890.46
Rate for Payer: Monida Montana Health Co-op	$872.10
Rate for Payer: Monida PacificSource	$872.10

REMOTE 30 DAY ECG REV/REPORT CON, REC, R

Facility

$360.00

Service Code	CPT 93270
Hospital Charge Code	193270
Hospital Revenue Code	731
Min. Negotiated Rate	$252.00
Max. Negotiated Rate	$360.00
Rate for Payer: Aetna Commercial	$342.00
Rate for Payer: Aetna Medicare	$324.00
Rate for Payer: BCBS MT CHIP	$324.00
Rate for Payer: BCBS MT Closed Plan Network	$342.00
Rate for Payer: BCBS MT HealthLink	$324.00
Rate for Payer: BCBS MT Medicare	$324.00
Rate for Payer: BCBS MT POS	$342.00
Rate for Payer: BCBS MT Traditional	$360.00
Rate for Payer: Cash Price	$324.00
Rate for Payer: Cigna Commercial	$342.00
Rate for Payer: Cigna Medicare	$324.00
Rate for Payer: Medicaid All Medicaid	$331.20
Rate for Payer: Medicare All Medicare	$252.00
Rate for Payer: Monida Allegiance	$342.00
Rate for Payer: Monida First Choice Health	$349.20
Rate for Payer: Monida Montana Health Co-op	$342.00
Rate for Payer: Monida PacificSource	$342.00

REMOTE 30 DAY ECG REV/REPORT CON, REC, R

Facility

$360.00

Service Code	CPT 93270
Hospital Charge Code	193270
Hospital Revenue Code	731
Min. Negotiated Rate	$252.00
Max. Negotiated Rate	$360.00
Rate for Payer: Aetna Commercial	$342.00
Rate for Payer: Aetna Medicare	$324.00
Rate for Payer: BCBS MT CHIP	$324.00
Rate for Payer: BCBS MT Closed Plan Network	$342.00
Rate for Payer: BCBS MT HealthLink	$324.00
Rate for Payer: BCBS MT Medicare	$324.00
Rate for Payer: BCBS MT POS	$342.00
Rate for Payer: BCBS MT Traditional	$360.00
Rate for Payer: Cash Price	$324.00
Rate for Payer: Cigna Commercial	$342.00
Rate for Payer: Cigna Medicare	$324.00
Rate for Payer: Medicaid All Medicaid	$331.20
Rate for Payer: Medicare All Medicare	$252.00
Rate for Payer: Monida Allegiance	$342.00
Rate for Payer: Monida First Choice Health	$349.20
Rate for Payer: Monida Montana Health Co-op	$342.00
Rate for Payer: Monida PacificSource	$342.00

REMOVAL BENIGN SKIN LES UP TO 15 (17110)

Facility

$182.00

Service Code	CPT 17110
Hospital Charge Code	8017110
Hospital Revenue Code	521
Min. Negotiated Rate	$127.40
Max. Negotiated Rate	$182.00
Rate for Payer: Aetna Commercial	$172.90
Rate for Payer: Aetna Medicare	$163.80
Rate for Payer: BCBS MT CHIP	$163.80
Rate for Payer: BCBS MT Closed Plan Network	$172.90
Rate for Payer: BCBS MT HealthLink	$163.80
Rate for Payer: BCBS MT Medicare	$163.80
Rate for Payer: BCBS MT POS	$172.90
Rate for Payer: BCBS MT Traditional	$182.00
Rate for Payer: Cash Price	$163.80
Rate for Payer: Cigna Commercial	$172.90
Rate for Payer: Cigna Medicare	$163.80
Rate for Payer: Medicaid All Medicaid	$167.44
Rate for Payer: Medicare All Medicare	$127.40
Rate for Payer: Monida Allegiance	$172.90
Rate for Payer: Monida First Choice Health	$176.54
Rate for Payer: Monida Montana Health Co-op	$172.90
Rate for Payer: Monida PacificSource	$172.90

REMOVAL BENIGN SKIN LES UP TO 15 (17110)

Facility

$182.00

Service Code	CPT 17110
Hospital Charge Code	8017110
Hospital Revenue Code	521
Min. Negotiated Rate	$127.40
Max. Negotiated Rate	$182.00
Rate for Payer: Aetna Commercial	$172.90
Rate for Payer: Aetna Medicare	$163.80
Rate for Payer: BCBS MT CHIP	$163.80
Rate for Payer: BCBS MT Closed Plan Network	$172.90
Rate for Payer: BCBS MT HealthLink	$163.80
Rate for Payer: BCBS MT Medicare	$163.80
Rate for Payer: BCBS MT POS	$172.90
Rate for Payer: BCBS MT Traditional	$182.00
Rate for Payer: Cash Price	$163.80
Rate for Payer: Cigna Commercial	$172.90
Rate for Payer: Cigna Medicare	$163.80
Rate for Payer: Medicaid All Medicaid	$167.44
Rate for Payer: Medicare All Medicare	$127.40
Rate for Payer: Monida Allegiance	$172.90
Rate for Payer: Monida First Choice Health	$176.54
Rate for Payer: Monida Montana Health Co-op	$172.90
Rate for Payer: Monida PacificSource	$172.90

REMOVAL FB CORNEAL WITH SLIT LAMP

Facility

$401.00

Service Code	CPT 65222
Hospital Charge Code	8065222
Hospital Revenue Code	521
Min. Negotiated Rate	$280.70
Max. Negotiated Rate	$401.00
Rate for Payer: Aetna Commercial	$380.95
Rate for Payer: Aetna Medicare	$360.90
Rate for Payer: BCBS MT CHIP	$360.90
Rate for Payer: BCBS MT Closed Plan Network	$380.95
Rate for Payer: BCBS MT HealthLink	$360.90
Rate for Payer: BCBS MT Medicare	$360.90
Rate for Payer: BCBS MT POS	$380.95
Rate for Payer: BCBS MT Traditional	$401.00
Rate for Payer: Cash Price	$360.90
Rate for Payer: Cigna Commercial	$380.95
Rate for Payer: Cigna Medicare	$360.90
Rate for Payer: Medicaid All Medicaid	$368.92
Rate for Payer: Medicare All Medicare	$280.70
Rate for Payer: Monida Allegiance	$380.95
Rate for Payer: Monida First Choice Health	$388.97
Rate for Payer: Monida Montana Health Co-op	$380.95
Rate for Payer: Monida PacificSource	$380.95

REMOVAL FB CORNEAL WITH SLIT LAMP

Facility

$401.00

Service Code	CPT 65222
Hospital Charge Code	8065222
Hospital Revenue Code	521
Min. Negotiated Rate	$280.70
Max. Negotiated Rate	$401.00
Rate for Payer: Aetna Commercial	$380.95
Rate for Payer: Aetna Medicare	$360.90
Rate for Payer: BCBS MT CHIP	$360.90
Rate for Payer: BCBS MT Closed Plan Network	$380.95
Rate for Payer: BCBS MT HealthLink	$360.90
Rate for Payer: BCBS MT Medicare	$360.90
Rate for Payer: BCBS MT POS	$380.95
Rate for Payer: BCBS MT Traditional	$401.00
Rate for Payer: Cash Price	$360.90
Rate for Payer: Cigna Commercial	$380.95
Rate for Payer: Cigna Medicare	$360.90
Rate for Payer: Medicaid All Medicaid	$368.92
Rate for Payer: Medicare All Medicare	$280.70
Rate for Payer: Monida Allegiance	$380.95
Rate for Payer: Monida First Choice Health	$388.97
Rate for Payer: Monida Montana Health Co-op	$380.95
Rate for Payer: Monida PacificSource	$380.95

REMOVAL FB CORNEAL W/O SLIT LAMP

Facility

$358.00

Service Code	CPT 65220
Hospital Charge Code	8065220
Hospital Revenue Code	521
Min. Negotiated Rate	$250.60
Max. Negotiated Rate	$358.00
Rate for Payer: Aetna Commercial	$340.10
Rate for Payer: Aetna Medicare	$322.20
Rate for Payer: BCBS MT CHIP	$322.20
Rate for Payer: BCBS MT Closed Plan Network	$340.10
Rate for Payer: BCBS MT HealthLink	$322.20
Rate for Payer: BCBS MT Medicare	$322.20
Rate for Payer: BCBS MT POS	$340.10
Rate for Payer: BCBS MT Traditional	$358.00
Rate for Payer: Cash Price	$322.20
Rate for Payer: Cigna Commercial	$340.10
Rate for Payer: Cigna Medicare	$322.20
Rate for Payer: Medicaid All Medicaid	$329.36
Rate for Payer: Medicare All Medicare	$250.60
Rate for Payer: Monida Allegiance	$340.10
Rate for Payer: Monida First Choice Health	$347.26
Rate for Payer: Monida Montana Health Co-op	$340.10
Rate for Payer: Monida PacificSource	$340.10

REMOVAL FB CORNEAL W/O SLIT LAMP

Facility

$358.00

Service Code	CPT 65220
Hospital Charge Code	8065220
Hospital Revenue Code	521
Min. Negotiated Rate	$250.60
Max. Negotiated Rate	$358.00
Rate for Payer: Aetna Commercial	$340.10
Rate for Payer: Aetna Medicare	$322.20
Rate for Payer: BCBS MT CHIP	$322.20
Rate for Payer: BCBS MT Closed Plan Network	$340.10
Rate for Payer: BCBS MT HealthLink	$322.20
Rate for Payer: BCBS MT Medicare	$322.20
Rate for Payer: BCBS MT POS	$340.10
Rate for Payer: BCBS MT Traditional	$358.00
Rate for Payer: Cash Price	$322.20
Rate for Payer: Cigna Commercial	$340.10
Rate for Payer: Cigna Medicare	$322.20
Rate for Payer: Medicaid All Medicaid	$329.36
Rate for Payer: Medicare All Medicare	$250.60
Rate for Payer: Monida Allegiance	$340.10
Rate for Payer: Monida First Choice Health	$347.26
Rate for Payer: Monida Montana Health Co-op	$340.10
Rate for Payer: Monida PacificSource	$340.10

REMOVAL FB EXTERNAL AUDITORY CANAL

Facility

$254.00

Service Code	CPT 69200
Hospital Charge Code	8069200
Hospital Revenue Code	521
Min. Negotiated Rate	$177.80
Max. Negotiated Rate	$254.00
Rate for Payer: Aetna Commercial	$241.30
Rate for Payer: Aetna Medicare	$228.60
Rate for Payer: BCBS MT CHIP	$228.60
Rate for Payer: BCBS MT Closed Plan Network	$241.30
Rate for Payer: BCBS MT HealthLink	$228.60
Rate for Payer: BCBS MT Medicare	$228.60
Rate for Payer: BCBS MT POS	$241.30
Rate for Payer: BCBS MT Traditional	$254.00
Rate for Payer: Cash Price	$228.60
Rate for Payer: Cigna Commercial	$241.30
Rate for Payer: Cigna Medicare	$228.60
Rate for Payer: Medicaid All Medicaid	$233.68
Rate for Payer: Medicare All Medicare	$177.80
Rate for Payer: Monida Allegiance	$241.30
Rate for Payer: Monida First Choice Health	$246.38
Rate for Payer: Monida Montana Health Co-op	$241.30
Rate for Payer: Monida PacificSource	$241.30

REMOVAL FB EXTERNAL AUDITORY CANAL

Facility

$254.00

Service Code	CPT 69200
Hospital Charge Code	8069200
Hospital Revenue Code	521
Min. Negotiated Rate	$177.80
Max. Negotiated Rate	$254.00
Rate for Payer: Aetna Commercial	$241.30
Rate for Payer: Aetna Medicare	$228.60
Rate for Payer: BCBS MT CHIP	$228.60
Rate for Payer: BCBS MT Closed Plan Network	$241.30
Rate for Payer: BCBS MT HealthLink	$228.60
Rate for Payer: BCBS MT Medicare	$228.60
Rate for Payer: BCBS MT POS	$241.30
Rate for Payer: BCBS MT Traditional	$254.00
Rate for Payer: Cash Price	$228.60
Rate for Payer: Cigna Commercial	$241.30
Rate for Payer: Cigna Medicare	$228.60
Rate for Payer: Medicaid All Medicaid	$233.68
Rate for Payer: Medicare All Medicare	$177.80
Rate for Payer: Monida Allegiance	$241.30
Rate for Payer: Monida First Choice Health	$246.38
Rate for Payer: Monida Montana Health Co-op	$241.30
Rate for Payer: Monida PacificSource	$241.30

REMOVAL FB EYE EXT CONJUNTIVAL SUPERFIC

Facility

$235.00

Service Code	CPT 65205
Hospital Charge Code	8065205
Hospital Revenue Code	521
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

REMOVAL FB EYE EXT CONJUNTIVAL SUPERFIC

Facility

$235.00

Service Code	CPT 65205
Hospital Charge Code	8065205
Hospital Revenue Code	521
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

REMOVAL FB FOOT SC SIMPLE

Facility

$607.00

Service Code	CPT 28190
Hospital Charge Code	8028190
Hospital Revenue Code	521
Min. Negotiated Rate	$424.90
Max. Negotiated Rate	$607.00
Rate for Payer: Aetna Commercial	$576.65
Rate for Payer: Aetna Medicare	$546.30
Rate for Payer: BCBS MT CHIP	$546.30
Rate for Payer: BCBS MT Closed Plan Network	$576.65
Rate for Payer: BCBS MT HealthLink	$546.30
Rate for Payer: BCBS MT Medicare	$546.30
Rate for Payer: BCBS MT POS	$576.65
Rate for Payer: BCBS MT Traditional	$607.00
Rate for Payer: Cash Price	$546.30
Rate for Payer: Cigna Commercial	$576.65
Rate for Payer: Cigna Medicare	$546.30
Rate for Payer: Medicaid All Medicaid	$558.44
Rate for Payer: Medicare All Medicare	$424.90
Rate for Payer: Monida Allegiance	$576.65
Rate for Payer: Monida First Choice Health	$588.79
Rate for Payer: Monida Montana Health Co-op	$576.65
Rate for Payer: Monida PacificSource	$576.65

REMOVAL FB FOOT SC SIMPLE

Facility

$607.00

Service Code	CPT 28190
Hospital Charge Code	8028190
Hospital Revenue Code	521
Min. Negotiated Rate	$424.90
Max. Negotiated Rate	$607.00
Rate for Payer: Aetna Commercial	$576.65
Rate for Payer: Aetna Medicare	$546.30
Rate for Payer: BCBS MT CHIP	$546.30
Rate for Payer: BCBS MT Closed Plan Network	$576.65
Rate for Payer: BCBS MT HealthLink	$546.30
Rate for Payer: BCBS MT Medicare	$546.30
Rate for Payer: BCBS MT POS	$576.65
Rate for Payer: BCBS MT Traditional	$607.00
Rate for Payer: Cash Price	$546.30
Rate for Payer: Cigna Commercial	$576.65
Rate for Payer: Cigna Medicare	$546.30
Rate for Payer: Medicaid All Medicaid	$558.44
Rate for Payer: Medicare All Medicare	$424.90
Rate for Payer: Monida Allegiance	$576.65
Rate for Payer: Monida First Choice Health	$588.79
Rate for Payer: Monida Montana Health Co-op	$576.65
Rate for Payer: Monida PacificSource	$576.65

REMOVAL FB INTRANASAL OFFICE TYPE TX

Facility

$342.00

Service Code	CPT 30300
Hospital Charge Code	8030300
Hospital Revenue Code	521
Min. Negotiated Rate	$239.40
Max. Negotiated Rate	$342.00
Rate for Payer: Aetna Commercial	$324.90
Rate for Payer: Aetna Medicare	$307.80
Rate for Payer: BCBS MT CHIP	$307.80
Rate for Payer: BCBS MT Closed Plan Network	$324.90
Rate for Payer: BCBS MT HealthLink	$307.80
Rate for Payer: BCBS MT Medicare	$307.80
Rate for Payer: BCBS MT POS	$324.90
Rate for Payer: BCBS MT Traditional	$342.00
Rate for Payer: Cash Price	$307.80
Rate for Payer: Cigna Commercial	$324.90
Rate for Payer: Cigna Medicare	$307.80
Rate for Payer: Medicaid All Medicaid	$314.64
Rate for Payer: Medicare All Medicare	$239.40
Rate for Payer: Monida Allegiance	$324.90
Rate for Payer: Monida First Choice Health	$331.74
Rate for Payer: Monida Montana Health Co-op	$324.90
Rate for Payer: Monida PacificSource	$324.90

REMOVAL FB INTRANASAL OFFICE TYPE TX

Facility

$342.00

Service Code	CPT 30300
Hospital Charge Code	8030300
Hospital Revenue Code	521
Min. Negotiated Rate	$239.40
Max. Negotiated Rate	$342.00
Rate for Payer: Aetna Commercial	$324.90
Rate for Payer: Aetna Medicare	$307.80
Rate for Payer: BCBS MT CHIP	$307.80
Rate for Payer: BCBS MT Closed Plan Network	$324.90
Rate for Payer: BCBS MT HealthLink	$307.80
Rate for Payer: BCBS MT Medicare	$307.80
Rate for Payer: BCBS MT POS	$324.90
Rate for Payer: BCBS MT Traditional	$342.00
Rate for Payer: Cash Price	$307.80
Rate for Payer: Cigna Commercial	$324.90
Rate for Payer: Cigna Medicare	$307.80
Rate for Payer: Medicaid All Medicaid	$314.64
Rate for Payer: Medicare All Medicare	$239.40
Rate for Payer: Monida Allegiance	$324.90
Rate for Payer: Monida First Choice Health	$331.74
Rate for Payer: Monida Montana Health Co-op	$324.90
Rate for Payer: Monida PacificSource	$324.90

REMOVAL FB MUSCLE/TENDON / DEEP OR COMPL

Facility

$3,792.00

Service Code	CPT 20525
Hospital Charge Code	8020525
Hospital Revenue Code	521
Min. Negotiated Rate	$2,654.40
Max. Negotiated Rate	$3,792.00
Rate for Payer: Aetna Commercial	$3,602.40
Rate for Payer: Aetna Medicare	$3,412.80
Rate for Payer: BCBS MT CHIP	$3,412.80
Rate for Payer: BCBS MT Closed Plan Network	$3,602.40
Rate for Payer: BCBS MT HealthLink	$3,412.80
Rate for Payer: BCBS MT Medicare	$3,412.80
Rate for Payer: BCBS MT POS	$3,602.40
Rate for Payer: BCBS MT Traditional	$3,792.00
Rate for Payer: Cash Price	$3,412.80
Rate for Payer: Cigna Commercial	$3,602.40
Rate for Payer: Cigna Medicare	$3,412.80
Rate for Payer: Medicaid All Medicaid	$3,488.64
Rate for Payer: Medicare All Medicare	$2,654.40
Rate for Payer: Monida Allegiance	$3,602.40
Rate for Payer: Monida First Choice Health	$3,678.24
Rate for Payer: Monida Montana Health Co-op	$3,602.40
Rate for Payer: Monida PacificSource	$3,602.40

REMOVAL FB MUSCLE/TENDON / DEEP OR COMPL

Facility

$3,792.00

Service Code	CPT 20525
Hospital Charge Code	8020525
Hospital Revenue Code	521
Min. Negotiated Rate	$2,654.40
Max. Negotiated Rate	$3,792.00
Rate for Payer: Aetna Commercial	$3,602.40
Rate for Payer: Aetna Medicare	$3,412.80
Rate for Payer: BCBS MT CHIP	$3,412.80
Rate for Payer: BCBS MT Closed Plan Network	$3,602.40
Rate for Payer: BCBS MT HealthLink	$3,412.80
Rate for Payer: BCBS MT Medicare	$3,412.80
Rate for Payer: BCBS MT POS	$3,602.40
Rate for Payer: BCBS MT Traditional	$3,792.00
Rate for Payer: Cash Price	$3,412.80
Rate for Payer: Cigna Commercial	$3,602.40
Rate for Payer: Cigna Medicare	$3,412.80
Rate for Payer: Medicaid All Medicaid	$3,488.64
Rate for Payer: Medicare All Medicare	$2,654.40
Rate for Payer: Monida Allegiance	$3,602.40
Rate for Payer: Monida First Choice Health	$3,678.24
Rate for Payer: Monida Montana Health Co-op	$3,602.40
Rate for Payer: Monida PacificSource	$3,602.40

Know your out-of-pocket cost for care.

All Charges