Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

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	CPT 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	CPT 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	CPT 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	CPT 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	CPT 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	CPT 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	CPT 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	CPT 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/REMVL-HOT BPSY FCPS 45384

Facility

$2,883.00

Service Code	CPT 45384
Hospital Charge Code	5845384
Hospital Revenue Code	750
Min. Negotiated Rate	$2,018.10
Max. Negotiated Rate	$2,883.00
Rate for Payer: Aetna Commercial	$2,738.85
Rate for Payer: Aetna Medicare	$2,594.70
Rate for Payer: BCBS MT CHIP	$2,594.70
Rate for Payer: BCBS MT Closed Plan Network	$2,738.85
Rate for Payer: BCBS MT HealthLink	$2,594.70
Rate for Payer: BCBS MT Medicare	$2,594.70
Rate for Payer: BCBS MT POS	$2,738.85
Rate for Payer: BCBS MT Traditional	$2,883.00
Rate for Payer: Cash Price	$2,594.70
Rate for Payer: Cigna Commercial	$2,738.85
Rate for Payer: Cigna Medicare	$2,594.70
Rate for Payer: Medicaid All Medicaid	$2,652.36
Rate for Payer: Medicare All Medicare	$2,018.10
Rate for Payer: Monida Allegiance	$2,738.85
Rate for Payer: Monida First Choice Health	$2,796.51
Rate for Payer: Monida Montana Health Co-op	$2,738.85
Rate for Payer: Monida PacificSource	$2,738.85

COLONOSCOPY W/REMVL-HOT BPSY FCPS 45384

Facility

$2,883.00

Service Code	CPT 45384
Hospital Charge Code	5845384
Hospital Revenue Code	750
Min. Negotiated Rate	$2,018.10
Max. Negotiated Rate	$2,883.00
Rate for Payer: Aetna Commercial	$2,738.85
Rate for Payer: Aetna Medicare	$2,594.70
Rate for Payer: BCBS MT CHIP	$2,594.70
Rate for Payer: BCBS MT Closed Plan Network	$2,738.85
Rate for Payer: BCBS MT HealthLink	$2,594.70
Rate for Payer: BCBS MT Medicare	$2,594.70
Rate for Payer: BCBS MT POS	$2,738.85
Rate for Payer: BCBS MT Traditional	$2,883.00
Rate for Payer: Cash Price	$2,594.70
Rate for Payer: Cigna Commercial	$2,738.85
Rate for Payer: Cigna Medicare	$2,594.70
Rate for Payer: Medicaid All Medicaid	$2,652.36
Rate for Payer: Medicare All Medicare	$2,018.10
Rate for Payer: Monida Allegiance	$2,738.85
Rate for Payer: Monida First Choice Health	$2,796.51
Rate for Payer: Monida Montana Health Co-op	$2,738.85
Rate for Payer: Monida PacificSource	$2,738.85

COLONOSCOPY W/RMVL-SNARE TECHNQ 45385

Facility

$2,882.00

Service Code	CPT 45385
Hospital Charge Code	5845385
Hospital Revenue Code	750
Min. Negotiated Rate	$2,017.40
Max. Negotiated Rate	$2,882.00
Rate for Payer: Aetna Commercial	$2,737.90
Rate for Payer: Aetna Medicare	$2,593.80
Rate for Payer: BCBS MT CHIP	$2,593.80
Rate for Payer: BCBS MT Closed Plan Network	$2,737.90
Rate for Payer: BCBS MT HealthLink	$2,593.80
Rate for Payer: BCBS MT Medicare	$2,593.80
Rate for Payer: BCBS MT POS	$2,737.90
Rate for Payer: BCBS MT Traditional	$2,882.00
Rate for Payer: Cash Price	$2,593.80
Rate for Payer: Cigna Commercial	$2,737.90
Rate for Payer: Cigna Medicare	$2,593.80
Rate for Payer: Medicaid All Medicaid	$2,651.44
Rate for Payer: Medicare All Medicare	$2,017.40
Rate for Payer: Monida Allegiance	$2,737.90
Rate for Payer: Monida First Choice Health	$2,795.54
Rate for Payer: Monida Montana Health Co-op	$2,737.90
Rate for Payer: Monida PacificSource	$2,737.90

COLONOSCOPY W/RMVL-SNARE TECHNQ 45385

Facility

$2,882.00

Service Code	CPT 45385
Hospital Charge Code	5845385
Hospital Revenue Code	750
Min. Negotiated Rate	$2,017.40
Max. Negotiated Rate	$2,882.00
Rate for Payer: Aetna Commercial	$2,737.90
Rate for Payer: Aetna Medicare	$2,593.80
Rate for Payer: BCBS MT CHIP	$2,593.80
Rate for Payer: BCBS MT Closed Plan Network	$2,737.90
Rate for Payer: BCBS MT HealthLink	$2,593.80
Rate for Payer: BCBS MT Medicare	$2,593.80
Rate for Payer: BCBS MT POS	$2,737.90
Rate for Payer: BCBS MT Traditional	$2,882.00
Rate for Payer: Cash Price	$2,593.80
Rate for Payer: Cigna Commercial	$2,737.90
Rate for Payer: Cigna Medicare	$2,593.80
Rate for Payer: Medicaid All Medicaid	$2,651.44
Rate for Payer: Medicare All Medicare	$2,017.40
Rate for Payer: Monida Allegiance	$2,737.90
Rate for Payer: Monida First Choice Health	$2,795.54
Rate for Payer: Monida Montana Health Co-op	$2,737.90
Rate for Payer: Monida PacificSource	$2,737.90

COLORECTAL CANCER SCREENING RESULTS DOCU

Facility

$0.01

Service Code	CPT 3017F
Hospital Charge Code	8003017
Hospital Revenue Code	521
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.01
Rate for Payer: Aetna Commercial	$0.01
Rate for Payer: Aetna Medicare	$0.01
Rate for Payer: BCBS MT CHIP	$0.01
Rate for Payer: BCBS MT Closed Plan Network	$0.01
Rate for Payer: BCBS MT HealthLink	$0.01
Rate for Payer: BCBS MT Medicare	$0.01
Rate for Payer: BCBS MT POS	$0.01
Rate for Payer: BCBS MT Traditional	$0.01
Rate for Payer: Cash Price	$0.01
Rate for Payer: Cigna Commercial	$0.01
Rate for Payer: Cigna Medicare	$0.01
Rate for Payer: Medicaid All Medicaid	$0.01
Rate for Payer: Medicare All Medicare	$0.01
Rate for Payer: Monida Allegiance	$0.01
Rate for Payer: Monida First Choice Health	$0.01
Rate for Payer: Monida Montana Health Co-op	$0.01
Rate for Payer: Monida PacificSource	$0.01

COLORECTAL CANCER SCREENING RESULTS DOCU

Facility

$0.01

Service Code	CPT 3017F
Hospital Charge Code	8003017
Hospital Revenue Code	521
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.01
Rate for Payer: Aetna Commercial	$0.01
Rate for Payer: Aetna Medicare	$0.01
Rate for Payer: BCBS MT CHIP	$0.01
Rate for Payer: BCBS MT Closed Plan Network	$0.01
Rate for Payer: BCBS MT HealthLink	$0.01
Rate for Payer: BCBS MT Medicare	$0.01
Rate for Payer: BCBS MT POS	$0.01
Rate for Payer: BCBS MT Traditional	$0.01
Rate for Payer: Cash Price	$0.01
Rate for Payer: Cigna Commercial	$0.01
Rate for Payer: Cigna Medicare	$0.01
Rate for Payer: Medicaid All Medicaid	$0.01
Rate for Payer: Medicare All Medicare	$0.01
Rate for Payer: Monida Allegiance	$0.01
Rate for Payer: Monida First Choice Health	$0.01
Rate for Payer: Monida Montana Health Co-op	$0.01
Rate for Payer: Monida PacificSource	$0.01

COMBIGAN OPHTH SOLN 0.2%-0.5%-NF

Facility

$563.40

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

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

$32.00

Hospital Charge Code	2893656
Hospital Revenue Code	290
Min. Negotiated Rate	$22.40
Max. Negotiated Rate	$32.00
Rate for Payer: Aetna Commercial	$30.40
Rate for Payer: Aetna Medicare	$28.80
Rate for Payer: BCBS MT CHIP	$28.80
Rate for Payer: BCBS MT Closed Plan Network	$30.40
Rate for Payer: BCBS MT HealthLink	$28.80
Rate for Payer: BCBS MT Medicare	$28.80
Rate for Payer: BCBS MT POS	$30.40
Rate for Payer: BCBS MT Traditional	$32.00
Rate for Payer: Cash Price	$28.80
Rate for Payer: Cigna Commercial	$30.40
Rate for Payer: Cigna Medicare	$28.80
Rate for Payer: Medicaid All Medicaid	$29.44
Rate for Payer: Medicare All Medicare	$22.40
Rate for Payer: Monida Allegiance	$30.40
Rate for Payer: Monida First Choice Health	$31.04
Rate for Payer: Monida Montana Health Co-op	$30.40
Rate for Payer: Monida PacificSource	$30.40

COMFORT FORM WRIST LT XLG

Facility

$32.00

Hospital Charge Code	2893656
Hospital Revenue Code	290
Min. Negotiated Rate	$22.40
Max. Negotiated Rate	$32.00
Rate for Payer: Aetna Commercial	$30.40
Rate for Payer: Aetna Medicare	$28.80
Rate for Payer: BCBS MT CHIP	$28.80
Rate for Payer: BCBS MT Closed Plan Network	$30.40
Rate for Payer: BCBS MT HealthLink	$28.80
Rate for Payer: BCBS MT Medicare	$28.80
Rate for Payer: BCBS MT POS	$30.40
Rate for Payer: BCBS MT Traditional	$32.00
Rate for Payer: Cash Price	$28.80
Rate for Payer: Cigna Commercial	$30.40
Rate for Payer: Cigna Medicare	$28.80
Rate for Payer: Medicaid All Medicaid	$29.44
Rate for Payer: Medicare All Medicare	$22.40
Rate for Payer: Monida Allegiance	$30.40
Rate for Payer: Monida First Choice Health	$31.04
Rate for Payer: Monida Montana Health Co-op	$30.40
Rate for Payer: Monida PacificSource	$30.40

COMFORT FORM WRIST RT L

Facility

$32.00

Hospital Charge Code	2893651
Hospital Revenue Code	290
Min. Negotiated Rate	$22.40
Max. Negotiated Rate	$32.00
Rate for Payer: Aetna Commercial	$30.40
Rate for Payer: Aetna Medicare	$28.80
Rate for Payer: BCBS MT CHIP	$28.80
Rate for Payer: BCBS MT Closed Plan Network	$30.40
Rate for Payer: BCBS MT HealthLink	$28.80
Rate for Payer: BCBS MT Medicare	$28.80
Rate for Payer: BCBS MT POS	$30.40
Rate for Payer: BCBS MT Traditional	$32.00
Rate for Payer: Cash Price	$28.80
Rate for Payer: Cigna Commercial	$30.40
Rate for Payer: Cigna Medicare	$28.80
Rate for Payer: Medicaid All Medicaid	$29.44
Rate for Payer: Medicare All Medicare	$22.40
Rate for Payer: Monida Allegiance	$30.40
Rate for Payer: Monida First Choice Health	$31.04
Rate for Payer: Monida Montana Health Co-op	$30.40
Rate for Payer: Monida PacificSource	$30.40

COMFORT FORM WRIST RT L

Facility

$32.00

Hospital Charge Code	2893651
Hospital Revenue Code	290
Min. Negotiated Rate	$22.40
Max. Negotiated Rate	$32.00
Rate for Payer: Aetna Commercial	$30.40
Rate for Payer: Aetna Medicare	$28.80
Rate for Payer: BCBS MT CHIP	$28.80
Rate for Payer: BCBS MT Closed Plan Network	$30.40
Rate for Payer: BCBS MT HealthLink	$28.80
Rate for Payer: BCBS MT Medicare	$28.80
Rate for Payer: BCBS MT POS	$30.40
Rate for Payer: BCBS MT Traditional	$32.00
Rate for Payer: Cash Price	$28.80
Rate for Payer: Cigna Commercial	$30.40
Rate for Payer: Cigna Medicare	$28.80
Rate for Payer: Medicaid All Medicaid	$29.44
Rate for Payer: Medicare All Medicare	$22.40
Rate for Payer: Monida Allegiance	$30.40
Rate for Payer: Monida First Choice Health	$31.04
Rate for Payer: Monida Montana Health Co-op	$30.40
Rate for Payer: Monida PacificSource	$30.40

COMFORT FORM WRIST RT M

Facility

$32.00

Hospital Charge Code	2893650
Hospital Revenue Code	290
Min. Negotiated Rate	$22.40
Max. Negotiated Rate	$32.00
Rate for Payer: Aetna Commercial	$30.40
Rate for Payer: Aetna Medicare	$28.80
Rate for Payer: BCBS MT CHIP	$28.80
Rate for Payer: BCBS MT Closed Plan Network	$30.40
Rate for Payer: BCBS MT HealthLink	$28.80
Rate for Payer: BCBS MT Medicare	$28.80
Rate for Payer: BCBS MT POS	$30.40
Rate for Payer: BCBS MT Traditional	$32.00
Rate for Payer: Cash Price	$28.80
Rate for Payer: Cigna Commercial	$30.40
Rate for Payer: Cigna Medicare	$28.80
Rate for Payer: Medicaid All Medicaid	$29.44
Rate for Payer: Medicare All Medicare	$22.40
Rate for Payer: Monida Allegiance	$30.40
Rate for Payer: Monida First Choice Health	$31.04
Rate for Payer: Monida Montana Health Co-op	$30.40
Rate for Payer: Monida PacificSource	$30.40

COMFORT FORM WRIST RT M

Facility

$32.00

Hospital Charge Code	2893650
Hospital Revenue Code	290
Min. Negotiated Rate	$22.40
Max. Negotiated Rate	$32.00
Rate for Payer: Aetna Commercial	$30.40
Rate for Payer: Aetna Medicare	$28.80
Rate for Payer: BCBS MT CHIP	$28.80
Rate for Payer: BCBS MT Closed Plan Network	$30.40
Rate for Payer: BCBS MT HealthLink	$28.80
Rate for Payer: BCBS MT Medicare	$28.80
Rate for Payer: BCBS MT POS	$30.40
Rate for Payer: BCBS MT Traditional	$32.00
Rate for Payer: Cash Price	$28.80
Rate for Payer: Cigna Commercial	$30.40
Rate for Payer: Cigna Medicare	$28.80
Rate for Payer: Medicaid All Medicaid	$29.44
Rate for Payer: Medicare All Medicare	$22.40
Rate for Payer: Monida Allegiance	$30.40
Rate for Payer: Monida First Choice Health	$31.04
Rate for Payer: Monida Montana Health Co-op	$30.40
Rate for Payer: Monida PacificSource	$30.40

Know your out-of-pocket cost for care.

All Charges