Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

COLLAR ADJ ADULT EXTRICAT

Facility

$40.00

Hospital Charge Code	80093320
Hospital Revenue Code	290
Min. Negotiated Rate	$28.00
Max. Negotiated Rate	$40.00
Rate for Payer: Aetna Commercial	$38.00
Rate for Payer: Aetna Medicare	$36.00
Rate for Payer: BCBS MT CHIP	$36.00
Rate for Payer: BCBS MT Closed Plan Network	$38.00
Rate for Payer: BCBS MT HealthLink	$36.00
Rate for Payer: BCBS MT Medicare	$36.00
Rate for Payer: BCBS MT POS	$38.00
Rate for Payer: BCBS MT Traditional	$40.00
Rate for Payer: Cash Price	$36.00
Rate for Payer: Cigna Commercial	$38.00
Rate for Payer: Cigna Medicare	$36.00
Rate for Payer: Medicaid All Medicaid	$36.80
Rate for Payer: Medicare All Medicare	$28.00
Rate for Payer: Monida Allegiance	$38.00
Rate for Payer: Monida First Choice Health	$38.80
Rate for Payer: Monida Montana Health Co-op	$38.00
Rate for Payer: Monida PacificSource	$38.00

COLLAR ADJ PEDS (EXTIRCATIO

Facility

$40.00

Hospital Charge Code	80093319
Hospital Revenue Code	290
Min. Negotiated Rate	$28.00
Max. Negotiated Rate	$40.00
Rate for Payer: Aetna Commercial	$38.00
Rate for Payer: Aetna Medicare	$36.00
Rate for Payer: BCBS MT CHIP	$36.00
Rate for Payer: BCBS MT Closed Plan Network	$38.00
Rate for Payer: BCBS MT HealthLink	$36.00
Rate for Payer: BCBS MT Medicare	$36.00
Rate for Payer: BCBS MT POS	$38.00
Rate for Payer: BCBS MT Traditional	$40.00
Rate for Payer: Cash Price	$36.00
Rate for Payer: Cigna Commercial	$38.00
Rate for Payer: Cigna Medicare	$36.00
Rate for Payer: Medicaid All Medicaid	$36.80
Rate for Payer: Medicare All Medicare	$28.00
Rate for Payer: Monida Allegiance	$38.00
Rate for Payer: Monida First Choice Health	$38.80
Rate for Payer: Monida Montana Health Co-op	$38.00
Rate for Payer: Monida PacificSource	$38.00

COLLAR ADJ PEDS (EXTIRCATIO

Facility

$40.00

Hospital Charge Code	80093319
Hospital Revenue Code	290
Min. Negotiated Rate	$28.00
Max. Negotiated Rate	$40.00
Rate for Payer: Aetna Commercial	$38.00
Rate for Payer: Aetna Medicare	$36.00
Rate for Payer: BCBS MT CHIP	$36.00
Rate for Payer: BCBS MT Closed Plan Network	$38.00
Rate for Payer: BCBS MT HealthLink	$36.00
Rate for Payer: BCBS MT Medicare	$36.00
Rate for Payer: BCBS MT POS	$38.00
Rate for Payer: BCBS MT Traditional	$40.00
Rate for Payer: Cash Price	$36.00
Rate for Payer: Cigna Commercial	$38.00
Rate for Payer: Cigna Medicare	$36.00
Rate for Payer: Medicaid All Medicaid	$36.80
Rate for Payer: Medicare All Medicare	$28.00
Rate for Payer: Monida Allegiance	$38.00
Rate for Payer: Monida First Choice Health	$38.80
Rate for Payer: Monida Montana Health Co-op	$38.00
Rate for Payer: Monida PacificSource	$38.00

COLLES SPLINT LT/LG W/PAD

Facility

$22.00

Hospital Charge Code	2893275
Hospital Revenue Code	290
Min. Negotiated Rate	$15.40
Max. Negotiated Rate	$22.00
Rate for Payer: Aetna Commercial	$20.90
Rate for Payer: Aetna Medicare	$19.80
Rate for Payer: BCBS MT CHIP	$19.80
Rate for Payer: BCBS MT Closed Plan Network	$20.90
Rate for Payer: BCBS MT HealthLink	$19.80
Rate for Payer: BCBS MT Medicare	$19.80
Rate for Payer: BCBS MT POS	$20.90
Rate for Payer: BCBS MT Traditional	$22.00
Rate for Payer: Cash Price	$19.80
Rate for Payer: Cigna Commercial	$20.90
Rate for Payer: Cigna Medicare	$19.80
Rate for Payer: Medicaid All Medicaid	$20.24
Rate for Payer: Medicare All Medicare	$15.40
Rate for Payer: Monida Allegiance	$20.90
Rate for Payer: Monida First Choice Health	$21.34
Rate for Payer: Monida Montana Health Co-op	$20.90
Rate for Payer: Monida PacificSource	$20.90

COLLES SPLINT LT/LG W/PAD

Facility

$22.00

Hospital Charge Code	2893275
Hospital Revenue Code	290
Min. Negotiated Rate	$15.40
Max. Negotiated Rate	$22.00
Rate for Payer: Aetna Commercial	$20.90
Rate for Payer: Aetna Medicare	$19.80
Rate for Payer: BCBS MT CHIP	$19.80
Rate for Payer: BCBS MT Closed Plan Network	$20.90
Rate for Payer: BCBS MT HealthLink	$19.80
Rate for Payer: BCBS MT Medicare	$19.80
Rate for Payer: BCBS MT POS	$20.90
Rate for Payer: BCBS MT Traditional	$22.00
Rate for Payer: Cash Price	$19.80
Rate for Payer: Cigna Commercial	$20.90
Rate for Payer: Cigna Medicare	$19.80
Rate for Payer: Medicaid All Medicaid	$20.24
Rate for Payer: Medicare All Medicare	$15.40
Rate for Payer: Monida Allegiance	$20.90
Rate for Payer: Monida First Choice Health	$21.34
Rate for Payer: Monida Montana Health Co-op	$20.90
Rate for Payer: Monida PacificSource	$20.90

COLLES SPLINT MED W/PAD

Facility

$22.00

Hospital Charge Code	2893274
Hospital Revenue Code	290
Min. Negotiated Rate	$15.40
Max. Negotiated Rate	$22.00
Rate for Payer: Aetna Commercial	$20.90
Rate for Payer: Aetna Medicare	$19.80
Rate for Payer: BCBS MT CHIP	$19.80
Rate for Payer: BCBS MT Closed Plan Network	$20.90
Rate for Payer: BCBS MT HealthLink	$19.80
Rate for Payer: BCBS MT Medicare	$19.80
Rate for Payer: BCBS MT POS	$20.90
Rate for Payer: BCBS MT Traditional	$22.00
Rate for Payer: Cash Price	$19.80
Rate for Payer: Cigna Commercial	$20.90
Rate for Payer: Cigna Medicare	$19.80
Rate for Payer: Medicaid All Medicaid	$20.24
Rate for Payer: Medicare All Medicare	$15.40
Rate for Payer: Monida Allegiance	$20.90
Rate for Payer: Monida First Choice Health	$21.34
Rate for Payer: Monida Montana Health Co-op	$20.90
Rate for Payer: Monida PacificSource	$20.90

COLLES SPLINT MED W/PAD

Facility

$22.00

Hospital Charge Code	2893274
Hospital Revenue Code	290
Min. Negotiated Rate	$15.40
Max. Negotiated Rate	$22.00
Rate for Payer: Aetna Commercial	$20.90
Rate for Payer: Aetna Medicare	$19.80
Rate for Payer: BCBS MT CHIP	$19.80
Rate for Payer: BCBS MT Closed Plan Network	$20.90
Rate for Payer: BCBS MT HealthLink	$19.80
Rate for Payer: BCBS MT Medicare	$19.80
Rate for Payer: BCBS MT POS	$20.90
Rate for Payer: BCBS MT Traditional	$22.00
Rate for Payer: Cash Price	$19.80
Rate for Payer: Cigna Commercial	$20.90
Rate for Payer: Cigna Medicare	$19.80
Rate for Payer: Medicaid All Medicaid	$20.24
Rate for Payer: Medicare All Medicare	$15.40
Rate for Payer: Monida Allegiance	$20.90
Rate for Payer: Monida First Choice Health	$21.34
Rate for Payer: Monida Montana Health Co-op	$20.90
Rate for Payer: Monida PacificSource	$20.90

COLLES SPLINT RT/LG W/PAD

Facility

$22.00

Hospital Charge Code	2893273
Hospital Revenue Code	290
Min. Negotiated Rate	$15.40
Max. Negotiated Rate	$22.00
Rate for Payer: Aetna Commercial	$20.90
Rate for Payer: Aetna Medicare	$19.80
Rate for Payer: BCBS MT CHIP	$19.80
Rate for Payer: BCBS MT Closed Plan Network	$20.90
Rate for Payer: BCBS MT HealthLink	$19.80
Rate for Payer: BCBS MT Medicare	$19.80
Rate for Payer: BCBS MT POS	$20.90
Rate for Payer: BCBS MT Traditional	$22.00
Rate for Payer: Cash Price	$19.80
Rate for Payer: Cigna Commercial	$20.90
Rate for Payer: Cigna Medicare	$19.80
Rate for Payer: Medicaid All Medicaid	$20.24
Rate for Payer: Medicare All Medicare	$15.40
Rate for Payer: Monida Allegiance	$20.90
Rate for Payer: Monida First Choice Health	$21.34
Rate for Payer: Monida Montana Health Co-op	$20.90
Rate for Payer: Monida PacificSource	$20.90

COLLES SPLINT RT/LG W/PAD

Facility

$22.00

Hospital Charge Code	2893273
Hospital Revenue Code	290
Min. Negotiated Rate	$15.40
Max. Negotiated Rate	$22.00
Rate for Payer: Aetna Commercial	$20.90
Rate for Payer: Aetna Medicare	$19.80
Rate for Payer: BCBS MT CHIP	$19.80
Rate for Payer: BCBS MT Closed Plan Network	$20.90
Rate for Payer: BCBS MT HealthLink	$19.80
Rate for Payer: BCBS MT Medicare	$19.80
Rate for Payer: BCBS MT POS	$20.90
Rate for Payer: BCBS MT Traditional	$22.00
Rate for Payer: Cash Price	$19.80
Rate for Payer: Cigna Commercial	$20.90
Rate for Payer: Cigna Medicare	$19.80
Rate for Payer: Medicaid All Medicaid	$20.24
Rate for Payer: Medicare All Medicare	$15.40
Rate for Payer: Monida Allegiance	$20.90
Rate for Payer: Monida First Choice Health	$21.34
Rate for Payer: Monida Montana Health Co-op	$20.90
Rate for Payer: Monida PacificSource	$20.90

COLLES SPLINT RT/MD W/PAD

Facility

$22.00

Hospital Charge Code	2893272
Hospital Revenue Code	290
Min. Negotiated Rate	$15.40
Max. Negotiated Rate	$22.00
Rate for Payer: Aetna Commercial	$20.90
Rate for Payer: Aetna Medicare	$19.80
Rate for Payer: BCBS MT CHIP	$19.80
Rate for Payer: BCBS MT Closed Plan Network	$20.90
Rate for Payer: BCBS MT HealthLink	$19.80
Rate for Payer: BCBS MT Medicare	$19.80
Rate for Payer: BCBS MT POS	$20.90
Rate for Payer: BCBS MT Traditional	$22.00
Rate for Payer: Cash Price	$19.80
Rate for Payer: Cigna Commercial	$20.90
Rate for Payer: Cigna Medicare	$19.80
Rate for Payer: Medicaid All Medicaid	$20.24
Rate for Payer: Medicare All Medicare	$15.40
Rate for Payer: Monida Allegiance	$20.90
Rate for Payer: Monida First Choice Health	$21.34
Rate for Payer: Monida Montana Health Co-op	$20.90
Rate for Payer: Monida PacificSource	$20.90

COLLES SPLINT RT/MD W/PAD

Facility

$22.00

Hospital Charge Code	2893272
Hospital Revenue Code	290
Min. Negotiated Rate	$15.40
Max. Negotiated Rate	$22.00
Rate for Payer: Aetna Commercial	$20.90
Rate for Payer: Aetna Medicare	$19.80
Rate for Payer: BCBS MT CHIP	$19.80
Rate for Payer: BCBS MT Closed Plan Network	$20.90
Rate for Payer: BCBS MT HealthLink	$19.80
Rate for Payer: BCBS MT Medicare	$19.80
Rate for Payer: BCBS MT POS	$20.90
Rate for Payer: BCBS MT Traditional	$22.00
Rate for Payer: Cash Price	$19.80
Rate for Payer: Cigna Commercial	$20.90
Rate for Payer: Cigna Medicare	$19.80
Rate for Payer: Medicaid All Medicaid	$20.24
Rate for Payer: Medicare All Medicare	$15.40
Rate for Payer: Monida Allegiance	$20.90
Rate for Payer: Monida First Choice Health	$21.34
Rate for Payer: Monida Montana Health Co-op	$20.90
Rate for Payer: Monida PacificSource	$20.90

COLONOSCOPY

Facility

$2,963.00

Service Code	HCPCS 45378
Hospital Charge Code	5845378
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

Facility

$2,963.00

Service Code	HCPCS 45378
Hospital Charge Code	5845378
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 SCREEN-PT HIGH RISK G0105

Facility

$2,822.00

Service Code	HCPCS G0105
Hospital Charge Code	5800105
Hospital Revenue Code	750
Min. Negotiated Rate	$1,975.40
Max. Negotiated Rate	$2,822.00
Rate for Payer: Aetna Commercial	$2,680.90
Rate for Payer: Aetna Medicare	$2,539.80
Rate for Payer: BCBS MT CHIP	$2,539.80
Rate for Payer: BCBS MT Closed Plan Network	$2,680.90
Rate for Payer: BCBS MT HealthLink	$2,539.80
Rate for Payer: BCBS MT Medicare	$2,539.80
Rate for Payer: BCBS MT POS	$2,680.90
Rate for Payer: BCBS MT Traditional	$2,822.00
Rate for Payer: Cash Price	$2,539.80
Rate for Payer: Cigna Commercial	$2,680.90
Rate for Payer: Cigna Medicare	$2,539.80
Rate for Payer: Medicaid All Medicaid	$2,596.24
Rate for Payer: Medicare All Medicare	$1,975.40
Rate for Payer: Monida Allegiance	$2,680.90
Rate for Payer: Monida First Choice Health	$2,737.34
Rate for Payer: Monida Montana Health Co-op	$2,680.90
Rate for Payer: Monida PacificSource	$2,680.90

COLONOSCOPY SCREEN-PT HIGH RISK G0105

Facility

$2,822.00

Service Code	HCPCS G0105
Hospital Charge Code	5800105
Hospital Revenue Code	750
Min. Negotiated Rate	$1,975.40
Max. Negotiated Rate	$2,822.00
Rate for Payer: Aetna Commercial	$2,680.90
Rate for Payer: Aetna Medicare	$2,539.80
Rate for Payer: BCBS MT CHIP	$2,539.80
Rate for Payer: BCBS MT Closed Plan Network	$2,680.90
Rate for Payer: BCBS MT HealthLink	$2,539.80
Rate for Payer: BCBS MT Medicare	$2,539.80
Rate for Payer: BCBS MT POS	$2,680.90
Rate for Payer: BCBS MT Traditional	$2,822.00
Rate for Payer: Cash Price	$2,539.80
Rate for Payer: Cigna Commercial	$2,680.90
Rate for Payer: Cigna Medicare	$2,539.80
Rate for Payer: Medicaid All Medicaid	$2,596.24
Rate for Payer: Medicare All Medicare	$1,975.40
Rate for Payer: Monida Allegiance	$2,680.90
Rate for Payer: Monida First Choice Health	$2,737.34
Rate for Payer: Monida Montana Health Co-op	$2,680.90
Rate for Payer: Monida PacificSource	$2,680.90

COLONOSCOPY SCRN-NOT MTG HIGH RISK G0121

Facility

$2,795.00

Service Code	HCPCS G0121
Hospital Charge Code	5800121
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 SCRN-NOT MTG HIGH RISK G0121

Facility

$2,795.00

Service Code	HCPCS G0121
Hospital Charge Code	5800121
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/ABLATION GUIDE WIRE 45388

Facility

$2,630.00

Service Code	HCPCS 45388
Hospital Charge Code	5845388
Hospital Revenue Code	750
Min. Negotiated Rate	$1,841.00
Max. Negotiated Rate	$2,630.00
Rate for Payer: Aetna Commercial	$2,498.50
Rate for Payer: Aetna Medicare	$2,367.00
Rate for Payer: BCBS MT CHIP	$2,367.00
Rate for Payer: BCBS MT Closed Plan Network	$2,498.50
Rate for Payer: BCBS MT HealthLink	$2,367.00
Rate for Payer: BCBS MT Medicare	$2,367.00
Rate for Payer: BCBS MT POS	$2,498.50
Rate for Payer: BCBS MT Traditional	$2,630.00
Rate for Payer: Cash Price	$2,367.00
Rate for Payer: Cigna Commercial	$2,498.50
Rate for Payer: Cigna Medicare	$2,367.00
Rate for Payer: Medicaid All Medicaid	$2,419.60
Rate for Payer: Medicare All Medicare	$1,841.00
Rate for Payer: Monida Allegiance	$2,498.50
Rate for Payer: Monida First Choice Health	$2,551.10
Rate for Payer: Monida Montana Health Co-op	$2,498.50
Rate for Payer: Monida PacificSource	$2,498.50

COLONOSCOPY W/ABLATION GUIDE WIRE 45388

Facility

$2,630.00

Service Code	HCPCS 45388
Hospital Charge Code	5845388
Hospital Revenue Code	750
Min. Negotiated Rate	$1,841.00
Max. Negotiated Rate	$2,630.00
Rate for Payer: Aetna Commercial	$2,498.50
Rate for Payer: Aetna Medicare	$2,367.00
Rate for Payer: BCBS MT CHIP	$2,367.00
Rate for Payer: BCBS MT Closed Plan Network	$2,498.50
Rate for Payer: BCBS MT HealthLink	$2,367.00
Rate for Payer: BCBS MT Medicare	$2,367.00
Rate for Payer: BCBS MT POS	$2,498.50
Rate for Payer: BCBS MT Traditional	$2,630.00
Rate for Payer: Cash Price	$2,367.00
Rate for Payer: Cigna Commercial	$2,498.50
Rate for Payer: Cigna Medicare	$2,367.00
Rate for Payer: Medicaid All Medicaid	$2,419.60
Rate for Payer: Medicare All Medicare	$1,841.00
Rate for Payer: Monida Allegiance	$2,498.50
Rate for Payer: Monida First Choice Health	$2,551.10
Rate for Payer: Monida Montana Health Co-op	$2,498.50
Rate for Payer: Monida PacificSource	$2,498.50

COLONOSCOPY W/ BIOPSY 45380

Facility

$3,141.00

Service Code	HCPCS 45380
Hospital Charge Code	5845380
Hospital Revenue Code	750
Min. Negotiated Rate	$2,198.70
Max. Negotiated Rate	$3,141.00
Rate for Payer: Aetna Commercial	$2,983.95
Rate for Payer: Aetna Medicare	$2,826.90
Rate for Payer: BCBS MT CHIP	$2,826.90
Rate for Payer: BCBS MT Closed Plan Network	$2,983.95
Rate for Payer: BCBS MT HealthLink	$2,826.90
Rate for Payer: BCBS MT Medicare	$2,826.90
Rate for Payer: BCBS MT POS	$2,983.95
Rate for Payer: BCBS MT Traditional	$3,141.00
Rate for Payer: Cash Price	$2,826.90
Rate for Payer: Cigna Commercial	$2,983.95
Rate for Payer: Cigna Medicare	$2,826.90
Rate for Payer: Medicaid All Medicaid	$2,889.72
Rate for Payer: Medicare All Medicare	$2,198.70
Rate for Payer: Monida Allegiance	$2,983.95
Rate for Payer: Monida First Choice Health	$3,046.77
Rate for Payer: Monida Montana Health Co-op	$2,983.95
Rate for Payer: Monida PacificSource	$2,983.95

COLONOSCOPY W/ BIOPSY 45380

Facility

$3,141.00

Service Code	HCPCS 45380
Hospital Charge Code	5845380
Hospital Revenue Code	750
Min. Negotiated Rate	$2,198.70
Max. Negotiated Rate	$3,141.00
Rate for Payer: Aetna Commercial	$2,983.95
Rate for Payer: Aetna Medicare	$2,826.90
Rate for Payer: BCBS MT CHIP	$2,826.90
Rate for Payer: BCBS MT Closed Plan Network	$2,983.95
Rate for Payer: BCBS MT HealthLink	$2,826.90
Rate for Payer: BCBS MT Medicare	$2,826.90
Rate for Payer: BCBS MT POS	$2,983.95
Rate for Payer: BCBS MT Traditional	$3,141.00
Rate for Payer: Cash Price	$2,826.90
Rate for Payer: Cigna Commercial	$2,983.95
Rate for Payer: Cigna Medicare	$2,826.90
Rate for Payer: Medicaid All Medicaid	$2,889.72
Rate for Payer: Medicare All Medicare	$2,198.70
Rate for Payer: Monida Allegiance	$2,983.95
Rate for Payer: Monida First Choice Health	$3,046.77
Rate for Payer: Monida Montana Health Co-op	$2,983.95
Rate for Payer: Monida PacificSource	$2,983.95

COLONOSCOPY W/CONTROL OF BLEEDNG 45382

Facility

$2,779.00

Service Code	HCPCS 45382
Hospital Charge Code	5845382
Hospital Revenue Code	750
Min. Negotiated Rate	$1,945.30
Max. Negotiated Rate	$2,779.00
Rate for Payer: Aetna Commercial	$2,640.05
Rate for Payer: Aetna Medicare	$2,501.10
Rate for Payer: BCBS MT CHIP	$2,501.10
Rate for Payer: BCBS MT Closed Plan Network	$2,640.05
Rate for Payer: BCBS MT HealthLink	$2,501.10
Rate for Payer: BCBS MT Medicare	$2,501.10
Rate for Payer: BCBS MT POS	$2,640.05
Rate for Payer: BCBS MT Traditional	$2,779.00
Rate for Payer: Cash Price	$2,501.10
Rate for Payer: Cigna Commercial	$2,640.05
Rate for Payer: Cigna Medicare	$2,501.10
Rate for Payer: Medicaid All Medicaid	$2,556.68
Rate for Payer: Medicare All Medicare	$1,945.30
Rate for Payer: Monida Allegiance	$2,640.05
Rate for Payer: Monida First Choice Health	$2,695.63
Rate for Payer: Monida Montana Health Co-op	$2,640.05
Rate for Payer: Monida PacificSource	$2,640.05

COLONOSCOPY W/CONTROL OF BLEEDNG 45382

Facility

$2,779.00

Service Code	HCPCS 45382
Hospital Charge Code	5845382
Hospital Revenue Code	750
Min. Negotiated Rate	$1,945.30
Max. Negotiated Rate	$2,779.00
Rate for Payer: Aetna Commercial	$2,640.05
Rate for Payer: Aetna Medicare	$2,501.10
Rate for Payer: BCBS MT CHIP	$2,501.10
Rate for Payer: BCBS MT Closed Plan Network	$2,640.05
Rate for Payer: BCBS MT HealthLink	$2,501.10
Rate for Payer: BCBS MT Medicare	$2,501.10
Rate for Payer: BCBS MT POS	$2,640.05
Rate for Payer: BCBS MT Traditional	$2,779.00
Rate for Payer: Cash Price	$2,501.10
Rate for Payer: Cigna Commercial	$2,640.05
Rate for Payer: Cigna Medicare	$2,501.10
Rate for Payer: Medicaid All Medicaid	$2,556.68
Rate for Payer: Medicare All Medicare	$1,945.30
Rate for Payer: Monida Allegiance	$2,640.05
Rate for Payer: Monida First Choice Health	$2,695.63
Rate for Payer: Monida Montana Health Co-op	$2,640.05
Rate for Payer: Monida PacificSource	$2,640.05

COLONOSCOPY W/DIRECTED SUBMUC INJ 45381

Facility

$2,963.00

Service Code	HCPCS 45381
Hospital Charge Code	5845381
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/DIRECTED SUBMUC INJ 45381

Facility

$2,963.00

Service Code	HCPCS 45381
Hospital Charge Code	5845381
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

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