Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

COLLES SPLINT RT/MD W/PAD

Facility

$21.00

Hospital Charge Code	2893272
Hospital Revenue Code	290
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

COLLES SPLINT RT/MD W/PAD

Facility

$21.00

Hospital Charge Code	2893272
Hospital Revenue Code	290
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

COLONOSCOPY 45378

Facility

$2,795.00

Service Code	HCPCS 45378
Hospital Charge Code	5845378
Hospital Revenue Code	750
Min. Negotiated Rate	$1,956.50
Max. Negotiated Rate	$2,795.00
Rate for Payer: Aetna Commercial	$2,655.25
Rate for Payer: Aetna Medicare	$2,515.50
Rate for Payer: BCBS MT CHIP	$2,515.50
Rate for Payer: BCBS MT Closed Plan Network	$2,655.25
Rate for Payer: BCBS MT HealthLink	$2,515.50
Rate for Payer: BCBS MT Medicare	$2,515.50
Rate for Payer: BCBS MT POS	$2,655.25
Rate for Payer: BCBS MT Traditional	$2,795.00
Rate for Payer: Cash Price	$2,515.50
Rate for Payer: Cigna Commercial	$2,655.25
Rate for Payer: Cigna Medicare	$2,515.50
Rate for Payer: Medicaid All Medicaid	$2,571.40
Rate for Payer: Medicare All Medicare	$1,956.50
Rate for Payer: Monida Allegiance	$2,655.25
Rate for Payer: Monida First Choice Health	$2,711.15
Rate for Payer: Monida Montana Health Co-op	$2,655.25
Rate for Payer: Monida PacificSource	$2,655.25

COLONOSCOPY 45378

Facility

$2,795.00

Service Code	HCPCS 45378
Hospital Charge Code	5845378
Hospital Revenue Code	750
Min. Negotiated Rate	$1,956.50
Max. Negotiated Rate	$2,795.00
Rate for Payer: Aetna Commercial	$2,655.25
Rate for Payer: Aetna Medicare	$2,515.50
Rate for Payer: BCBS MT CHIP	$2,515.50
Rate for Payer: BCBS MT Closed Plan Network	$2,655.25
Rate for Payer: BCBS MT HealthLink	$2,515.50
Rate for Payer: BCBS MT Medicare	$2,515.50
Rate for Payer: BCBS MT POS	$2,655.25
Rate for Payer: BCBS MT Traditional	$2,795.00
Rate for Payer: Cash Price	$2,515.50
Rate for Payer: Cigna Commercial	$2,655.25
Rate for Payer: Cigna Medicare	$2,515.50
Rate for Payer: Medicaid All Medicaid	$2,571.40
Rate for Payer: Medicare All Medicare	$1,956.50
Rate for Payer: Monida Allegiance	$2,655.25
Rate for Payer: Monida First Choice Health	$2,711.15
Rate for Payer: Monida Montana Health Co-op	$2,655.25
Rate for Payer: Monida PacificSource	$2,655.25

COLONOSCOPY W/ BIOPSY 45380

Facility

$2,963.00

Service Code	HCPCS 45380
Hospital Charge Code	5845380
Hospital Revenue Code	750
Min. Negotiated Rate	$2,074.10
Max. Negotiated Rate	$2,963.00
Rate for Payer: Aetna Commercial	$2,814.85
Rate for Payer: Aetna Medicare	$2,666.70
Rate for Payer: BCBS MT CHIP	$2,666.70
Rate for Payer: BCBS MT Closed Plan Network	$2,814.85
Rate for Payer: BCBS MT HealthLink	$2,666.70
Rate for Payer: BCBS MT Medicare	$2,666.70
Rate for Payer: BCBS MT POS	$2,814.85
Rate for Payer: BCBS MT Traditional	$2,963.00
Rate for Payer: Cash Price	$2,666.70
Rate for Payer: Cigna Commercial	$2,814.85
Rate for Payer: Cigna Medicare	$2,666.70
Rate for Payer: Medicaid All Medicaid	$2,725.96
Rate for Payer: Medicare All Medicare	$2,074.10
Rate for Payer: Monida Allegiance	$2,814.85
Rate for Payer: Monida First Choice Health	$2,874.11
Rate for Payer: Monida Montana Health Co-op	$2,814.85
Rate for Payer: Monida PacificSource	$2,814.85

COLONOSCOPY W/ BIOPSY 45380

Facility

$2,963.00

Service Code	HCPCS 45380
Hospital Charge Code	5845380
Hospital Revenue Code	750
Min. Negotiated Rate	$2,074.10
Max. Negotiated Rate	$2,963.00
Rate for Payer: Aetna Commercial	$2,814.85
Rate for Payer: Aetna Medicare	$2,666.70
Rate for Payer: BCBS MT CHIP	$2,666.70
Rate for Payer: BCBS MT Closed Plan Network	$2,814.85
Rate for Payer: BCBS MT HealthLink	$2,666.70
Rate for Payer: BCBS MT Medicare	$2,666.70
Rate for Payer: BCBS MT POS	$2,814.85
Rate for Payer: BCBS MT Traditional	$2,963.00
Rate for Payer: Cash Price	$2,666.70
Rate for Payer: Cigna Commercial	$2,814.85
Rate for Payer: Cigna Medicare	$2,666.70
Rate for Payer: Medicaid All Medicaid	$2,725.96
Rate for Payer: Medicare All Medicare	$2,074.10
Rate for Payer: Monida Allegiance	$2,814.85
Rate for Payer: Monida First Choice Health	$2,874.11
Rate for Payer: Monida Montana Health Co-op	$2,814.85
Rate for Payer: Monida PacificSource	$2,814.85

COMBIGAN OPHTH SOLN 0.2%-0.5%-NF

Facility

$563.40

Service Code	NDC 00023921105
Hospital Charge Code	3007265
Hospital Revenue Code	250
Min. Negotiated Rate	$394.38
Max. Negotiated Rate	$563.40
Rate for Payer: Aetna Commercial	$535.23
Rate for Payer: Aetna Medicare	$507.06
Rate for Payer: BCBS MT CHIP	$507.06
Rate for Payer: BCBS MT Closed Plan Network	$535.23
Rate for Payer: BCBS MT HealthLink	$507.06
Rate for Payer: BCBS MT Medicare	$507.06
Rate for Payer: BCBS MT POS	$535.23
Rate for Payer: BCBS MT Traditional	$563.40
Rate for Payer: Cash Price	$507.06
Rate for Payer: Cigna Commercial	$535.23
Rate for Payer: Cigna Medicare	$507.06
Rate for Payer: Medicaid All Medicaid	$518.33
Rate for Payer: Medicare All Medicare	$394.38
Rate for Payer: Monida Allegiance	$535.23
Rate for Payer: Monida First Choice Health	$546.50
Rate for Payer: Monida Montana Health Co-op	$535.23
Rate for Payer: Monida PacificSource	$535.23

COMBIGAN OPHTH SOLN 0.2%-0.5%-NF

Facility

$563.40

Service Code	NDC 00023921105
Hospital Charge Code	3007265
Hospital Revenue Code	250
Min. Negotiated Rate	$394.38
Max. Negotiated Rate	$563.40
Rate for Payer: Aetna Commercial	$535.23
Rate for Payer: Aetna Medicare	$507.06
Rate for Payer: BCBS MT CHIP	$507.06
Rate for Payer: BCBS MT Closed Plan Network	$535.23
Rate for Payer: BCBS MT HealthLink	$507.06
Rate for Payer: BCBS MT Medicare	$507.06
Rate for Payer: BCBS MT POS	$535.23
Rate for Payer: BCBS MT Traditional	$563.40
Rate for Payer: Cash Price	$507.06
Rate for Payer: Cigna Commercial	$535.23
Rate for Payer: Cigna Medicare	$507.06
Rate for Payer: Medicaid All Medicaid	$518.33
Rate for Payer: Medicare All Medicare	$394.38
Rate for Payer: Monida Allegiance	$535.23
Rate for Payer: Monida First Choice Health	$546.50
Rate for Payer: Monida Montana Health Co-op	$535.23
Rate for Payer: Monida PacificSource	$535.23

COMFORT FORM WRIST LT XLG

Facility

$30.00

Hospital Charge Code	2893656
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

COMFORT FORM WRIST LT XLG

Facility

$30.00

Hospital Charge Code	2893656
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

COMFORT FORM WRIST RT L

Facility

$30.00

Hospital Charge Code	2893651
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

COMFORT FORM WRIST RT L

Facility

$30.00

Hospital Charge Code	2893651
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

COMFORT FORM WRIST RT M

Facility

$30.00

Hospital Charge Code	2893650
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

COMFORT FORM WRIST RT M

Facility

$30.00

Hospital Charge Code	2893650
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

COMFORT FORM WRIST RT S

Facility

$37.00

Service Code	HCPCS L3908
Hospital Charge Code	2861597
Hospital Revenue Code	270
Min. Negotiated Rate	$25.90
Max. Negotiated Rate	$37.00
Rate for Payer: Aetna Commercial	$35.15
Rate for Payer: Aetna Medicare	$33.30
Rate for Payer: BCBS MT CHIP	$33.30
Rate for Payer: BCBS MT Closed Plan Network	$35.15
Rate for Payer: BCBS MT HealthLink	$33.30
Rate for Payer: BCBS MT Medicare	$33.30
Rate for Payer: BCBS MT POS	$35.15
Rate for Payer: BCBS MT Traditional	$37.00
Rate for Payer: Cash Price	$33.30
Rate for Payer: Cigna Commercial	$35.15
Rate for Payer: Cigna Medicare	$33.30
Rate for Payer: Medicaid All Medicaid	$34.04
Rate for Payer: Medicare All Medicare	$25.90
Rate for Payer: Monida Allegiance	$35.15
Rate for Payer: Monida First Choice Health	$35.89
Rate for Payer: Monida Montana Health Co-op	$35.15
Rate for Payer: Monida PacificSource	$35.15

COMFORT FORM WRIST RT S

Facility

$37.00

Service Code	HCPCS L3908
Hospital Charge Code	2861597
Hospital Revenue Code	270
Min. Negotiated Rate	$25.90
Max. Negotiated Rate	$37.00
Rate for Payer: Aetna Commercial	$35.15
Rate for Payer: Aetna Medicare	$33.30
Rate for Payer: BCBS MT CHIP	$33.30
Rate for Payer: BCBS MT Closed Plan Network	$35.15
Rate for Payer: BCBS MT HealthLink	$33.30
Rate for Payer: BCBS MT Medicare	$33.30
Rate for Payer: BCBS MT POS	$35.15
Rate for Payer: BCBS MT Traditional	$37.00
Rate for Payer: Cash Price	$33.30
Rate for Payer: Cigna Commercial	$35.15
Rate for Payer: Cigna Medicare	$33.30
Rate for Payer: Medicaid All Medicaid	$34.04
Rate for Payer: Medicare All Medicare	$25.90
Rate for Payer: Monida Allegiance	$35.15
Rate for Payer: Monida First Choice Health	$35.89
Rate for Payer: Monida Montana Health Co-op	$35.15
Rate for Payer: Monida PacificSource	$35.15

COMFORT FORM WRIST RT XLG

Facility

$30.00

Hospital Charge Code	2893652
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

COMFORT FORM WRIST RT XLG

Facility

$30.00

Hospital Charge Code	2893652
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

COMPLEMENT C1Q (016824)

Facility

$47.00

Service Code	HCPCS 86160
Hospital Charge Code	4086160
Hospital Revenue Code	300
Min. Negotiated Rate	$32.90
Max. Negotiated Rate	$47.00
Rate for Payer: Aetna Commercial	$44.65
Rate for Payer: Aetna Medicare	$42.30
Rate for Payer: BCBS MT CHIP	$42.30
Rate for Payer: BCBS MT Closed Plan Network	$44.65
Rate for Payer: BCBS MT HealthLink	$42.30
Rate for Payer: BCBS MT Medicare	$42.30
Rate for Payer: BCBS MT POS	$44.65
Rate for Payer: BCBS MT Traditional	$47.00
Rate for Payer: Cash Price	$42.30
Rate for Payer: Cigna Commercial	$44.65
Rate for Payer: Cigna Medicare	$42.30
Rate for Payer: Medicaid All Medicaid	$43.24
Rate for Payer: Medicare All Medicare	$32.90
Rate for Payer: Monida Allegiance	$44.65
Rate for Payer: Monida First Choice Health	$45.59
Rate for Payer: Monida Montana Health Co-op	$44.65
Rate for Payer: Monida PacificSource	$44.65

COMPLEMENT C1Q (016824)

Facility

$47.00

Service Code	HCPCS 86160
Hospital Charge Code	4086160
Hospital Revenue Code	300
Min. Negotiated Rate	$32.90
Max. Negotiated Rate	$47.00
Rate for Payer: Aetna Commercial	$44.65
Rate for Payer: Aetna Medicare	$42.30
Rate for Payer: BCBS MT CHIP	$42.30
Rate for Payer: BCBS MT Closed Plan Network	$44.65
Rate for Payer: BCBS MT HealthLink	$42.30
Rate for Payer: BCBS MT Medicare	$42.30
Rate for Payer: BCBS MT POS	$44.65
Rate for Payer: BCBS MT Traditional	$47.00
Rate for Payer: Cash Price	$42.30
Rate for Payer: Cigna Commercial	$44.65
Rate for Payer: Cigna Medicare	$42.30
Rate for Payer: Medicaid All Medicaid	$43.24
Rate for Payer: Medicare All Medicare	$32.90
Rate for Payer: Monida Allegiance	$44.65
Rate for Payer: Monida First Choice Health	$45.59
Rate for Payer: Monida Montana Health Co-op	$44.65
Rate for Payer: Monida PacificSource	$44.65

COMPLEMENT C3 (006452)

Facility

$16.00

Service Code	HCPCS 86160
Hospital Charge Code	4000051
Hospital Revenue Code	300
Min. Negotiated Rate	$11.20
Max. Negotiated Rate	$16.00
Rate for Payer: Aetna Commercial	$15.20
Rate for Payer: Aetna Medicare	$14.40
Rate for Payer: BCBS MT CHIP	$14.40
Rate for Payer: BCBS MT Closed Plan Network	$15.20
Rate for Payer: BCBS MT HealthLink	$14.40
Rate for Payer: BCBS MT Medicare	$14.40
Rate for Payer: BCBS MT POS	$15.20
Rate for Payer: BCBS MT Traditional	$16.00
Rate for Payer: Cash Price	$14.40
Rate for Payer: Cigna Commercial	$15.20
Rate for Payer: Cigna Medicare	$14.40
Rate for Payer: Medicaid All Medicaid	$14.72
Rate for Payer: Medicare All Medicare	$11.20
Rate for Payer: Monida Allegiance	$15.20
Rate for Payer: Monida First Choice Health	$15.52
Rate for Payer: Monida Montana Health Co-op	$15.20
Rate for Payer: Monida PacificSource	$15.20

COMPLEMENT C3 (006452)

Facility

$16.00

Service Code	HCPCS 86160
Hospital Charge Code	4000051
Hospital Revenue Code	300
Min. Negotiated Rate	$11.20
Max. Negotiated Rate	$16.00
Rate for Payer: Aetna Commercial	$15.20
Rate for Payer: Aetna Medicare	$14.40
Rate for Payer: BCBS MT CHIP	$14.40
Rate for Payer: BCBS MT Closed Plan Network	$15.20
Rate for Payer: BCBS MT HealthLink	$14.40
Rate for Payer: BCBS MT Medicare	$14.40
Rate for Payer: BCBS MT POS	$15.20
Rate for Payer: BCBS MT Traditional	$16.00
Rate for Payer: Cash Price	$14.40
Rate for Payer: Cigna Commercial	$15.20
Rate for Payer: Cigna Medicare	$14.40
Rate for Payer: Medicaid All Medicaid	$14.72
Rate for Payer: Medicare All Medicare	$11.20
Rate for Payer: Monida Allegiance	$15.20
Rate for Payer: Monida First Choice Health	$15.52
Rate for Payer: Monida Montana Health Co-op	$15.20
Rate for Payer: Monida PacificSource	$15.20

COMPLEMENT C4 (001834)

Facility

$16.00

Service Code	HCPCS 86160
Hospital Charge Code	4000052
Hospital Revenue Code	300
Min. Negotiated Rate	$11.20
Max. Negotiated Rate	$16.00
Rate for Payer: Aetna Commercial	$15.20
Rate for Payer: Aetna Medicare	$14.40
Rate for Payer: BCBS MT CHIP	$14.40
Rate for Payer: BCBS MT Closed Plan Network	$15.20
Rate for Payer: BCBS MT HealthLink	$14.40
Rate for Payer: BCBS MT Medicare	$14.40
Rate for Payer: BCBS MT POS	$15.20
Rate for Payer: BCBS MT Traditional	$16.00
Rate for Payer: Cash Price	$14.40
Rate for Payer: Cigna Commercial	$15.20
Rate for Payer: Cigna Medicare	$14.40
Rate for Payer: Medicaid All Medicaid	$14.72
Rate for Payer: Medicare All Medicare	$11.20
Rate for Payer: Monida Allegiance	$15.20
Rate for Payer: Monida First Choice Health	$15.52
Rate for Payer: Monida Montana Health Co-op	$15.20
Rate for Payer: Monida PacificSource	$15.20

COMPLEMENT C4 (001834)

Facility

$16.00

Service Code	HCPCS 86160
Hospital Charge Code	4000052
Hospital Revenue Code	300
Min. Negotiated Rate	$11.20
Max. Negotiated Rate	$16.00
Rate for Payer: Aetna Commercial	$15.20
Rate for Payer: Aetna Medicare	$14.40
Rate for Payer: BCBS MT CHIP	$14.40
Rate for Payer: BCBS MT Closed Plan Network	$15.20
Rate for Payer: BCBS MT HealthLink	$14.40
Rate for Payer: BCBS MT Medicare	$14.40
Rate for Payer: BCBS MT POS	$15.20
Rate for Payer: BCBS MT Traditional	$16.00
Rate for Payer: Cash Price	$14.40
Rate for Payer: Cigna Commercial	$15.20
Rate for Payer: Cigna Medicare	$14.40
Rate for Payer: Medicaid All Medicaid	$14.72
Rate for Payer: Medicare All Medicare	$11.20
Rate for Payer: Monida Allegiance	$15.20
Rate for Payer: Monida First Choice Health	$15.52
Rate for Payer: Monida Montana Health Co-op	$15.20
Rate for Payer: Monida PacificSource	$15.20

COMPLEMENT, TOTAL (001941)

Facility

$16.00

Service Code	HCPCS 86162
Hospital Charge Code	4086162
Hospital Revenue Code	302
Min. Negotiated Rate	$11.20
Max. Negotiated Rate	$16.00
Rate for Payer: Aetna Commercial	$15.20
Rate for Payer: Aetna Medicare	$14.40
Rate for Payer: BCBS MT CHIP	$14.40
Rate for Payer: BCBS MT Closed Plan Network	$15.20
Rate for Payer: BCBS MT HealthLink	$14.40
Rate for Payer: BCBS MT Medicare	$14.40
Rate for Payer: BCBS MT POS	$15.20
Rate for Payer: BCBS MT Traditional	$16.00
Rate for Payer: Cash Price	$14.40
Rate for Payer: Cigna Commercial	$15.20
Rate for Payer: Cigna Medicare	$14.40
Rate for Payer: Medicaid All Medicaid	$14.72
Rate for Payer: Medicare All Medicare	$11.20
Rate for Payer: Monida Allegiance	$15.20
Rate for Payer: Monida First Choice Health	$15.52
Rate for Payer: Monida Montana Health Co-op	$15.20
Rate for Payer: Monida PacificSource	$15.20

Know your out-of-pocket cost for care.

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