Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

SHAMPOO CAP

Facility

$12.00

Hospital Charge Code	80040156
Hospital Revenue Code	270
Min. Negotiated Rate	$8.40
Max. Negotiated Rate	$12.00
Rate for Payer: Aetna Commercial	$11.40
Rate for Payer: Aetna Medicare	$10.80
Rate for Payer: BCBS MT CHIP	$10.80
Rate for Payer: BCBS MT Closed Plan Network	$11.40
Rate for Payer: BCBS MT HealthLink	$10.80
Rate for Payer: BCBS MT Medicare	$10.80
Rate for Payer: BCBS MT POS	$11.40
Rate for Payer: BCBS MT Traditional	$12.00
Rate for Payer: Cash Price	$10.80
Rate for Payer: Cigna Commercial	$11.40
Rate for Payer: Cigna Medicare	$10.80
Rate for Payer: Medicaid All Medicaid	$11.04
Rate for Payer: Medicare All Medicare	$8.40
Rate for Payer: Monida Allegiance	$11.40
Rate for Payer: Monida First Choice Health	$11.64
Rate for Payer: Monida Montana Health Co-op	$11.40
Rate for Payer: Monida PacificSource	$11.40

SHAMPOO CAP

Facility

$12.00

Hospital Charge Code	80040156
Hospital Revenue Code	270
Min. Negotiated Rate	$8.40
Max. Negotiated Rate	$12.00
Rate for Payer: Aetna Commercial	$11.40
Rate for Payer: Aetna Medicare	$10.80
Rate for Payer: BCBS MT CHIP	$10.80
Rate for Payer: BCBS MT Closed Plan Network	$11.40
Rate for Payer: BCBS MT HealthLink	$10.80
Rate for Payer: BCBS MT Medicare	$10.80
Rate for Payer: BCBS MT POS	$11.40
Rate for Payer: BCBS MT Traditional	$12.00
Rate for Payer: Cash Price	$10.80
Rate for Payer: Cigna Commercial	$11.40
Rate for Payer: Cigna Medicare	$10.80
Rate for Payer: Medicaid All Medicaid	$11.04
Rate for Payer: Medicare All Medicare	$8.40
Rate for Payer: Monida Allegiance	$11.40
Rate for Payer: Monida First Choice Health	$11.64
Rate for Payer: Monida Montana Health Co-op	$11.40
Rate for Payer: Monida PacificSource	$11.40

SHAVE SKIN LESION 0.5 CM OR LESS (11305)

Facility

$219.00

Service Code	CPT 11305
Hospital Charge Code	8011305
Hospital Revenue Code	521
Min. Negotiated Rate	$153.30
Max. Negotiated Rate	$219.00
Rate for Payer: Aetna Commercial	$208.05
Rate for Payer: Aetna Medicare	$197.10
Rate for Payer: BCBS MT CHIP	$197.10
Rate for Payer: BCBS MT Closed Plan Network	$208.05
Rate for Payer: BCBS MT HealthLink	$197.10
Rate for Payer: BCBS MT Medicare	$197.10
Rate for Payer: BCBS MT POS	$208.05
Rate for Payer: BCBS MT Traditional	$219.00
Rate for Payer: Cash Price	$197.10
Rate for Payer: Cigna Commercial	$208.05
Rate for Payer: Cigna Medicare	$197.10
Rate for Payer: Medicaid All Medicaid	$201.48
Rate for Payer: Medicare All Medicare	$153.30
Rate for Payer: Monida Allegiance	$208.05
Rate for Payer: Monida First Choice Health	$212.43
Rate for Payer: Monida Montana Health Co-op	$208.05
Rate for Payer: Monida PacificSource	$208.05

SHAVE SKIN LESION 0.5 CM OR LESS (11305)

Facility

$219.00

Service Code	CPT 11305
Hospital Charge Code	8011305
Hospital Revenue Code	521
Min. Negotiated Rate	$153.30
Max. Negotiated Rate	$219.00
Rate for Payer: Aetna Commercial	$208.05
Rate for Payer: Aetna Medicare	$197.10
Rate for Payer: BCBS MT CHIP	$197.10
Rate for Payer: BCBS MT Closed Plan Network	$208.05
Rate for Payer: BCBS MT HealthLink	$197.10
Rate for Payer: BCBS MT Medicare	$197.10
Rate for Payer: BCBS MT POS	$208.05
Rate for Payer: BCBS MT Traditional	$219.00
Rate for Payer: Cash Price	$197.10
Rate for Payer: Cigna Commercial	$208.05
Rate for Payer: Cigna Medicare	$197.10
Rate for Payer: Medicaid All Medicaid	$201.48
Rate for Payer: Medicare All Medicare	$153.30
Rate for Payer: Monida Allegiance	$208.05
Rate for Payer: Monida First Choice Health	$212.43
Rate for Payer: Monida Montana Health Co-op	$208.05
Rate for Payer: Monida PacificSource	$208.05

SHAVE SKIN LESION 0.6-1CM (11301)

Facility

$217.00

Service Code	CPT 11301
Hospital Charge Code	8011301
Hospital Revenue Code	521
Min. Negotiated Rate	$151.90
Max. Negotiated Rate	$217.00
Rate for Payer: Aetna Commercial	$206.15
Rate for Payer: Aetna Medicare	$195.30
Rate for Payer: BCBS MT CHIP	$195.30
Rate for Payer: BCBS MT Closed Plan Network	$206.15
Rate for Payer: BCBS MT HealthLink	$195.30
Rate for Payer: BCBS MT Medicare	$195.30
Rate for Payer: BCBS MT POS	$206.15
Rate for Payer: BCBS MT Traditional	$217.00
Rate for Payer: Cash Price	$195.30
Rate for Payer: Cigna Commercial	$206.15
Rate for Payer: Cigna Medicare	$195.30
Rate for Payer: Medicaid All Medicaid	$199.64
Rate for Payer: Medicare All Medicare	$151.90
Rate for Payer: Monida Allegiance	$206.15
Rate for Payer: Monida First Choice Health	$210.49
Rate for Payer: Monida Montana Health Co-op	$206.15
Rate for Payer: Monida PacificSource	$206.15

SHAVE SKIN LESION 0.6-1CM (11301)

Facility

$217.00

Service Code	CPT 11301
Hospital Charge Code	8011301
Hospital Revenue Code	521
Min. Negotiated Rate	$151.90
Max. Negotiated Rate	$217.00
Rate for Payer: Aetna Commercial	$206.15
Rate for Payer: Aetna Medicare	$195.30
Rate for Payer: BCBS MT CHIP	$195.30
Rate for Payer: BCBS MT Closed Plan Network	$206.15
Rate for Payer: BCBS MT HealthLink	$195.30
Rate for Payer: BCBS MT Medicare	$195.30
Rate for Payer: BCBS MT POS	$206.15
Rate for Payer: BCBS MT Traditional	$217.00
Rate for Payer: Cash Price	$195.30
Rate for Payer: Cigna Commercial	$206.15
Rate for Payer: Cigna Medicare	$195.30
Rate for Payer: Medicaid All Medicaid	$199.64
Rate for Payer: Medicare All Medicare	$151.90
Rate for Payer: Monida Allegiance	$206.15
Rate for Payer: Monida First Choice Health	$210.49
Rate for Payer: Monida Montana Health Co-op	$206.15
Rate for Payer: Monida PacificSource	$206.15

SHAVE SKIN LESION 0.6CM to 1.0CM (11306)

Facility

$234.00

Service Code	CPT 11306
Hospital Charge Code	8011306
Hospital Revenue Code	521
Min. Negotiated Rate	$163.80
Max. Negotiated Rate	$234.00
Rate for Payer: Aetna Commercial	$222.30
Rate for Payer: Aetna Medicare	$210.60
Rate for Payer: BCBS MT CHIP	$210.60
Rate for Payer: BCBS MT Closed Plan Network	$222.30
Rate for Payer: BCBS MT HealthLink	$210.60
Rate for Payer: BCBS MT Medicare	$210.60
Rate for Payer: BCBS MT POS	$222.30
Rate for Payer: BCBS MT Traditional	$234.00
Rate for Payer: Cash Price	$210.60
Rate for Payer: Cigna Commercial	$222.30
Rate for Payer: Cigna Medicare	$210.60
Rate for Payer: Medicaid All Medicaid	$215.28
Rate for Payer: Medicare All Medicare	$163.80
Rate for Payer: Monida Allegiance	$222.30
Rate for Payer: Monida First Choice Health	$226.98
Rate for Payer: Monida Montana Health Co-op	$222.30
Rate for Payer: Monida PacificSource	$222.30

SHAVE SKIN LESION 0.6CM to 1.0CM (11306)

Facility

$234.00

Service Code	CPT 11306
Hospital Charge Code	8011306
Hospital Revenue Code	521
Min. Negotiated Rate	$163.80
Max. Negotiated Rate	$234.00
Rate for Payer: Aetna Commercial	$222.30
Rate for Payer: Aetna Medicare	$210.60
Rate for Payer: BCBS MT CHIP	$210.60
Rate for Payer: BCBS MT Closed Plan Network	$222.30
Rate for Payer: BCBS MT HealthLink	$210.60
Rate for Payer: BCBS MT Medicare	$210.60
Rate for Payer: BCBS MT POS	$222.30
Rate for Payer: BCBS MT Traditional	$234.00
Rate for Payer: Cash Price	$210.60
Rate for Payer: Cigna Commercial	$222.30
Rate for Payer: Cigna Medicare	$210.60
Rate for Payer: Medicaid All Medicaid	$215.28
Rate for Payer: Medicare All Medicare	$163.80
Rate for Payer: Monida Allegiance	$222.30
Rate for Payer: Monida First Choice Health	$226.98
Rate for Payer: Monida Montana Health Co-op	$222.30
Rate for Payer: Monida PacificSource	$222.30

SHAVE SKIN LESION 1.1-2.0CM (11302)

Facility

$247.00

Service Code	CPT 11302
Hospital Charge Code	8011302
Hospital Revenue Code	521
Min. Negotiated Rate	$172.90
Max. Negotiated Rate	$247.00
Rate for Payer: Aetna Commercial	$234.65
Rate for Payer: Aetna Medicare	$222.30
Rate for Payer: BCBS MT CHIP	$222.30
Rate for Payer: BCBS MT Closed Plan Network	$234.65
Rate for Payer: BCBS MT HealthLink	$222.30
Rate for Payer: BCBS MT Medicare	$222.30
Rate for Payer: BCBS MT POS	$234.65
Rate for Payer: BCBS MT Traditional	$247.00
Rate for Payer: Cash Price	$222.30
Rate for Payer: Cigna Commercial	$234.65
Rate for Payer: Cigna Medicare	$222.30
Rate for Payer: Medicaid All Medicaid	$227.24
Rate for Payer: Medicare All Medicare	$172.90
Rate for Payer: Monida Allegiance	$234.65
Rate for Payer: Monida First Choice Health	$239.59
Rate for Payer: Monida Montana Health Co-op	$234.65
Rate for Payer: Monida PacificSource	$234.65

SHAVE SKIN LESION 1.1-2.0CM (11302)

Facility

$247.00

Service Code	CPT 11302
Hospital Charge Code	8011302
Hospital Revenue Code	521
Min. Negotiated Rate	$172.90
Max. Negotiated Rate	$247.00
Rate for Payer: Aetna Commercial	$234.65
Rate for Payer: Aetna Medicare	$222.30
Rate for Payer: BCBS MT CHIP	$222.30
Rate for Payer: BCBS MT Closed Plan Network	$234.65
Rate for Payer: BCBS MT HealthLink	$222.30
Rate for Payer: BCBS MT Medicare	$222.30
Rate for Payer: BCBS MT POS	$234.65
Rate for Payer: BCBS MT Traditional	$247.00
Rate for Payer: Cash Price	$222.30
Rate for Payer: Cigna Commercial	$234.65
Rate for Payer: Cigna Medicare	$222.30
Rate for Payer: Medicaid All Medicaid	$227.24
Rate for Payer: Medicare All Medicare	$172.90
Rate for Payer: Monida Allegiance	$234.65
Rate for Payer: Monida First Choice Health	$239.59
Rate for Payer: Monida Montana Health Co-op	$234.65
Rate for Payer: Monida PacificSource	$234.65

SHAVE SKIN LESION >2.0CM (11303)

Facility

$279.00

Service Code	CPT 11303
Hospital Charge Code	8011303
Hospital Revenue Code	521
Min. Negotiated Rate	$195.30
Max. Negotiated Rate	$279.00
Rate for Payer: Aetna Commercial	$265.05
Rate for Payer: Aetna Medicare	$251.10
Rate for Payer: BCBS MT CHIP	$251.10
Rate for Payer: BCBS MT Closed Plan Network	$265.05
Rate for Payer: BCBS MT HealthLink	$251.10
Rate for Payer: BCBS MT Medicare	$251.10
Rate for Payer: BCBS MT POS	$265.05
Rate for Payer: BCBS MT Traditional	$279.00
Rate for Payer: Cash Price	$251.10
Rate for Payer: Cigna Commercial	$265.05
Rate for Payer: Cigna Medicare	$251.10
Rate for Payer: Medicaid All Medicaid	$256.68
Rate for Payer: Medicare All Medicare	$195.30
Rate for Payer: Monida Allegiance	$265.05
Rate for Payer: Monida First Choice Health	$270.63
Rate for Payer: Monida Montana Health Co-op	$265.05
Rate for Payer: Monida PacificSource	$265.05

SHAVE SKIN LESION >2.0CM (11303)

Facility

$279.00

Service Code	CPT 11303
Hospital Charge Code	8011303
Hospital Revenue Code	521
Min. Negotiated Rate	$195.30
Max. Negotiated Rate	$279.00
Rate for Payer: Aetna Commercial	$265.05
Rate for Payer: Aetna Medicare	$251.10
Rate for Payer: BCBS MT CHIP	$251.10
Rate for Payer: BCBS MT Closed Plan Network	$265.05
Rate for Payer: BCBS MT HealthLink	$251.10
Rate for Payer: BCBS MT Medicare	$251.10
Rate for Payer: BCBS MT POS	$265.05
Rate for Payer: BCBS MT Traditional	$279.00
Rate for Payer: Cash Price	$251.10
Rate for Payer: Cigna Commercial	$265.05
Rate for Payer: Cigna Medicare	$251.10
Rate for Payer: Medicaid All Medicaid	$256.68
Rate for Payer: Medicare All Medicare	$195.30
Rate for Payer: Monida Allegiance	$265.05
Rate for Payer: Monida First Choice Health	$270.63
Rate for Payer: Monida Montana Health Co-op	$265.05
Rate for Payer: Monida PacificSource	$265.05

SHAVE SKIN LESION >.5CM (11300)

Facility

$182.00

Service Code	CPT 11300
Hospital Charge Code	8011300
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

SHAVE SKIN LESION >.5CM (11300)

Facility

$182.00

Service Code	CPT 11300
Hospital Charge Code	8011300
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

.SHIGA-LIKE TOXIN

Facility

$25.00

Service Code	CPT 87427
Hospital Charge Code	4087427
Hospital Revenue Code	306
Min. Negotiated Rate	$17.50
Max. Negotiated Rate	$25.00
Rate for Payer: Aetna Commercial	$23.75
Rate for Payer: Aetna Medicare	$22.50
Rate for Payer: BCBS MT CHIP	$22.50
Rate for Payer: BCBS MT Closed Plan Network	$23.75
Rate for Payer: BCBS MT HealthLink	$22.50
Rate for Payer: BCBS MT Medicare	$22.50
Rate for Payer: BCBS MT POS	$23.75
Rate for Payer: BCBS MT Traditional	$25.00
Rate for Payer: Cash Price	$22.50
Rate for Payer: Cigna Commercial	$23.75
Rate for Payer: Cigna Medicare	$22.50
Rate for Payer: Medicaid All Medicaid	$23.00
Rate for Payer: Medicare All Medicare	$17.50
Rate for Payer: Monida Allegiance	$23.75
Rate for Payer: Monida First Choice Health	$24.25
Rate for Payer: Monida Montana Health Co-op	$23.75
Rate for Payer: Monida PacificSource	$23.75

.SHIGA-LIKE TOXIN

Facility

$25.00

Service Code	CPT 87427
Hospital Charge Code	4087427
Hospital Revenue Code	306
Min. Negotiated Rate	$17.50
Max. Negotiated Rate	$25.00
Rate for Payer: Aetna Commercial	$23.75
Rate for Payer: Aetna Medicare	$22.50
Rate for Payer: BCBS MT CHIP	$22.50
Rate for Payer: BCBS MT Closed Plan Network	$23.75
Rate for Payer: BCBS MT HealthLink	$22.50
Rate for Payer: BCBS MT Medicare	$22.50
Rate for Payer: BCBS MT POS	$23.75
Rate for Payer: BCBS MT Traditional	$25.00
Rate for Payer: Cash Price	$22.50
Rate for Payer: Cigna Commercial	$23.75
Rate for Payer: Cigna Medicare	$22.50
Rate for Payer: Medicaid All Medicaid	$23.00
Rate for Payer: Medicare All Medicare	$17.50
Rate for Payer: Monida Allegiance	$23.75
Rate for Payer: Monida First Choice Health	$24.25
Rate for Payer: Monida Montana Health Co-op	$23.75
Rate for Payer: Monida PacificSource	$23.75

SHOULDER IMMOB MD

Facility

$30.00

Hospital Charge Code	2893508
Hospital Revenue Code	290
Min. Negotiated Rate	$21.00
Max. Negotiated Rate	$30.00
Rate for Payer: Aetna Commercial	$28.50
Rate for Payer: Aetna Medicare	$27.00
Rate for Payer: BCBS MT CHIP	$27.00
Rate for Payer: BCBS MT Closed Plan Network	$28.50
Rate for Payer: BCBS MT HealthLink	$27.00
Rate for Payer: BCBS MT Medicare	$27.00
Rate for Payer: BCBS MT POS	$28.50
Rate for Payer: BCBS MT Traditional	$30.00
Rate for Payer: Cash Price	$27.00
Rate for Payer: Cigna Commercial	$28.50
Rate for Payer: Cigna Medicare	$27.00
Rate for Payer: Medicaid All Medicaid	$27.60
Rate for Payer: Medicare All Medicare	$21.00
Rate for Payer: Monida Allegiance	$28.50
Rate for Payer: Monida First Choice Health	$29.10
Rate for Payer: Monida Montana Health Co-op	$28.50
Rate for Payer: Monida PacificSource	$28.50

SHOULDER IMMOB MD

Facility

$30.00

Hospital Charge Code	2893508
Hospital Revenue Code	290
Min. Negotiated Rate	$21.00
Max. Negotiated Rate	$30.00
Rate for Payer: Aetna Commercial	$28.50
Rate for Payer: Aetna Medicare	$27.00
Rate for Payer: BCBS MT CHIP	$27.00
Rate for Payer: BCBS MT Closed Plan Network	$28.50
Rate for Payer: BCBS MT HealthLink	$27.00
Rate for Payer: BCBS MT Medicare	$27.00
Rate for Payer: BCBS MT POS	$28.50
Rate for Payer: BCBS MT Traditional	$30.00
Rate for Payer: Cash Price	$27.00
Rate for Payer: Cigna Commercial	$28.50
Rate for Payer: Cigna Medicare	$27.00
Rate for Payer: Medicaid All Medicaid	$27.60
Rate for Payer: Medicare All Medicare	$21.00
Rate for Payer: Monida Allegiance	$28.50
Rate for Payer: Monida First Choice Health	$29.10
Rate for Payer: Monida Montana Health Co-op	$28.50
Rate for Payer: Monida PacificSource	$28.50

SHOULDER IMMOBSM

Facility

$34.00

Hospital Charge Code	2893509
Hospital Revenue Code	290
Min. Negotiated Rate	$23.80
Max. Negotiated Rate	$34.00
Rate for Payer: Aetna Commercial	$32.30
Rate for Payer: Aetna Medicare	$30.60
Rate for Payer: BCBS MT CHIP	$30.60
Rate for Payer: BCBS MT Closed Plan Network	$32.30
Rate for Payer: BCBS MT HealthLink	$30.60
Rate for Payer: BCBS MT Medicare	$30.60
Rate for Payer: BCBS MT POS	$32.30
Rate for Payer: BCBS MT Traditional	$34.00
Rate for Payer: Cash Price	$30.60
Rate for Payer: Cigna Commercial	$32.30
Rate for Payer: Cigna Medicare	$30.60
Rate for Payer: Medicaid All Medicaid	$31.28
Rate for Payer: Medicare All Medicare	$23.80
Rate for Payer: Monida Allegiance	$32.30
Rate for Payer: Monida First Choice Health	$32.98
Rate for Payer: Monida Montana Health Co-op	$32.30
Rate for Payer: Monida PacificSource	$32.30

SHOULDER IMMOBSM

Facility

$34.00

Hospital Charge Code	2893509
Hospital Revenue Code	290
Min. Negotiated Rate	$23.80
Max. Negotiated Rate	$34.00
Rate for Payer: Aetna Commercial	$32.30
Rate for Payer: Aetna Medicare	$30.60
Rate for Payer: BCBS MT CHIP	$30.60
Rate for Payer: BCBS MT Closed Plan Network	$32.30
Rate for Payer: BCBS MT HealthLink	$30.60
Rate for Payer: BCBS MT Medicare	$30.60
Rate for Payer: BCBS MT POS	$32.30
Rate for Payer: BCBS MT Traditional	$34.00
Rate for Payer: Cash Price	$30.60
Rate for Payer: Cigna Commercial	$32.30
Rate for Payer: Cigna Medicare	$30.60
Rate for Payer: Medicaid All Medicaid	$31.28
Rate for Payer: Medicare All Medicare	$23.80
Rate for Payer: Monida Allegiance	$32.30
Rate for Payer: Monida First Choice Health	$32.98
Rate for Payer: Monida Montana Health Co-op	$32.30
Rate for Payer: Monida PacificSource	$32.30

SHOULDER IMMOB. XLG

Facility

$27.00

Hospital Charge Code	2846183
Hospital Revenue Code	270
Min. Negotiated Rate	$18.90
Max. Negotiated Rate	$27.00
Rate for Payer: Aetna Commercial	$25.65
Rate for Payer: Aetna Medicare	$24.30
Rate for Payer: BCBS MT CHIP	$24.30
Rate for Payer: BCBS MT Closed Plan Network	$25.65
Rate for Payer: BCBS MT HealthLink	$24.30
Rate for Payer: BCBS MT Medicare	$24.30
Rate for Payer: BCBS MT POS	$25.65
Rate for Payer: BCBS MT Traditional	$27.00
Rate for Payer: Cash Price	$24.30
Rate for Payer: Cigna Commercial	$25.65
Rate for Payer: Cigna Medicare	$24.30
Rate for Payer: Medicaid All Medicaid	$24.84
Rate for Payer: Medicare All Medicare	$18.90
Rate for Payer: Monida Allegiance	$25.65
Rate for Payer: Monida First Choice Health	$26.19
Rate for Payer: Monida Montana Health Co-op	$25.65
Rate for Payer: Monida PacificSource	$25.65

SHOULDER IMMOB. XLG

Facility

$27.00

Hospital Charge Code	2846183
Hospital Revenue Code	270
Min. Negotiated Rate	$18.90
Max. Negotiated Rate	$27.00
Rate for Payer: Aetna Commercial	$25.65
Rate for Payer: Aetna Medicare	$24.30
Rate for Payer: BCBS MT CHIP	$24.30
Rate for Payer: BCBS MT Closed Plan Network	$25.65
Rate for Payer: BCBS MT HealthLink	$24.30
Rate for Payer: BCBS MT Medicare	$24.30
Rate for Payer: BCBS MT POS	$25.65
Rate for Payer: BCBS MT Traditional	$27.00
Rate for Payer: Cash Price	$24.30
Rate for Payer: Cigna Commercial	$25.65
Rate for Payer: Cigna Medicare	$24.30
Rate for Payer: Medicaid All Medicaid	$24.84
Rate for Payer: Medicare All Medicare	$18.90
Rate for Payer: Monida Allegiance	$25.65
Rate for Payer: Monida First Choice Health	$26.19
Rate for Payer: Monida Montana Health Co-op	$25.65
Rate for Payer: Monida PacificSource	$25.65

SHOULDER IMMOB. XSM

Facility

$27.00

Hospital Charge Code	2846182
Hospital Revenue Code	270
Min. Negotiated Rate	$18.90
Max. Negotiated Rate	$27.00
Rate for Payer: Aetna Commercial	$25.65
Rate for Payer: Aetna Medicare	$24.30
Rate for Payer: BCBS MT CHIP	$24.30
Rate for Payer: BCBS MT Closed Plan Network	$25.65
Rate for Payer: BCBS MT HealthLink	$24.30
Rate for Payer: BCBS MT Medicare	$24.30
Rate for Payer: BCBS MT POS	$25.65
Rate for Payer: BCBS MT Traditional	$27.00
Rate for Payer: Cash Price	$24.30
Rate for Payer: Cigna Commercial	$25.65
Rate for Payer: Cigna Medicare	$24.30
Rate for Payer: Medicaid All Medicaid	$24.84
Rate for Payer: Medicare All Medicare	$18.90
Rate for Payer: Monida Allegiance	$25.65
Rate for Payer: Monida First Choice Health	$26.19
Rate for Payer: Monida Montana Health Co-op	$25.65
Rate for Payer: Monida PacificSource	$25.65

SHOULDER IMMOB. XSM

Facility

$27.00

Hospital Charge Code	2846182
Hospital Revenue Code	270
Min. Negotiated Rate	$18.90
Max. Negotiated Rate	$27.00
Rate for Payer: Aetna Commercial	$25.65
Rate for Payer: Aetna Medicare	$24.30
Rate for Payer: BCBS MT CHIP	$24.30
Rate for Payer: BCBS MT Closed Plan Network	$25.65
Rate for Payer: BCBS MT HealthLink	$24.30
Rate for Payer: BCBS MT Medicare	$24.30
Rate for Payer: BCBS MT POS	$25.65
Rate for Payer: BCBS MT Traditional	$27.00
Rate for Payer: Cash Price	$24.30
Rate for Payer: Cigna Commercial	$25.65
Rate for Payer: Cigna Medicare	$24.30
Rate for Payer: Medicaid All Medicaid	$24.84
Rate for Payer: Medicare All Medicare	$18.90
Rate for Payer: Monida Allegiance	$25.65
Rate for Payer: Monida First Choice Health	$26.19
Rate for Payer: Monida Montana Health Co-op	$25.65
Rate for Payer: Monida PacificSource	$25.65

SICKLE SOLUBILITY 85660

Facility

$72.00

Service Code	CPT 85660
Hospital Charge Code	4085660
Hospital Revenue Code	305
Min. Negotiated Rate	$50.40
Max. Negotiated Rate	$72.00
Rate for Payer: Aetna Commercial	$68.40
Rate for Payer: Aetna Medicare	$64.80
Rate for Payer: BCBS MT CHIP	$64.80
Rate for Payer: BCBS MT Closed Plan Network	$68.40
Rate for Payer: BCBS MT HealthLink	$64.80
Rate for Payer: BCBS MT Medicare	$64.80
Rate for Payer: BCBS MT POS	$68.40
Rate for Payer: BCBS MT Traditional	$72.00
Rate for Payer: Cash Price	$64.80
Rate for Payer: Cigna Commercial	$68.40
Rate for Payer: Cigna Medicare	$64.80
Rate for Payer: Medicaid All Medicaid	$66.24
Rate for Payer: Medicare All Medicare	$50.40
Rate for Payer: Monida Allegiance	$68.40
Rate for Payer: Monida First Choice Health	$69.84
Rate for Payer: Monida Montana Health Co-op	$68.40
Rate for Payer: Monida PacificSource	$68.40

Know your out-of-pocket cost for care.

All Charges