Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

.ENTEROVIRUS ANTIBODIES

Facility

$7.09

Service Code	HCPCS 86658
Hospital Charge Code	4086658
Hospital Revenue Code	306
Min. Negotiated Rate	$4.96
Max. Negotiated Rate	$7.09
Rate for Payer: Aetna Commercial	$6.74
Rate for Payer: Aetna Medicare	$6.38
Rate for Payer: BCBS MT CHIP	$6.38
Rate for Payer: BCBS MT Closed Plan Network	$6.74
Rate for Payer: BCBS MT HealthLink	$6.38
Rate for Payer: BCBS MT Medicare	$6.38
Rate for Payer: BCBS MT POS	$6.74
Rate for Payer: BCBS MT Traditional	$7.09
Rate for Payer: Cash Price	$6.38
Rate for Payer: Cigna Commercial	$6.74
Rate for Payer: Cigna Medicare	$6.38
Rate for Payer: Medicaid All Medicaid	$6.52
Rate for Payer: Medicare All Medicare	$4.96
Rate for Payer: Monida Allegiance	$6.74
Rate for Payer: Monida First Choice Health	$6.88
Rate for Payer: Monida Montana Health Co-op	$6.74
Rate for Payer: Monida PacificSource	$6.74

.ENTEROVIRUS ANTIBODIES

Facility

$7.09

Service Code	HCPCS 86658
Hospital Charge Code	4086658
Hospital Revenue Code	306
Min. Negotiated Rate	$4.96
Max. Negotiated Rate	$7.09
Rate for Payer: Aetna Commercial	$6.74
Rate for Payer: Aetna Medicare	$6.38
Rate for Payer: BCBS MT CHIP	$6.38
Rate for Payer: BCBS MT Closed Plan Network	$6.74
Rate for Payer: BCBS MT HealthLink	$6.38
Rate for Payer: BCBS MT Medicare	$6.38
Rate for Payer: BCBS MT POS	$6.74
Rate for Payer: BCBS MT Traditional	$7.09
Rate for Payer: Cash Price	$6.38
Rate for Payer: Cigna Commercial	$6.74
Rate for Payer: Cigna Medicare	$6.38
Rate for Payer: Medicaid All Medicaid	$6.52
Rate for Payer: Medicare All Medicare	$4.96
Rate for Payer: Monida Allegiance	$6.74
Rate for Payer: Monida First Choice Health	$6.88
Rate for Payer: Monida Montana Health Co-op	$6.74
Rate for Payer: Monida PacificSource	$6.74

ePHEDrine INJ [50 MG/ML]

Facility

$112.00

Service Code	HCPCS J3490
Hospital Charge Code	3000143
Hospital Revenue Code	250
Min. Negotiated Rate	$78.40
Max. Negotiated Rate	$112.00
Rate for Payer: Aetna Commercial	$106.40
Rate for Payer: Aetna Medicare	$100.80
Rate for Payer: BCBS MT CHIP	$100.80
Rate for Payer: BCBS MT Closed Plan Network	$106.40
Rate for Payer: BCBS MT HealthLink	$100.80
Rate for Payer: BCBS MT Medicare	$100.80
Rate for Payer: BCBS MT POS	$106.40
Rate for Payer: BCBS MT Traditional	$112.00
Rate for Payer: Cash Price	$100.80
Rate for Payer: Cigna Commercial	$106.40
Rate for Payer: Cigna Medicare	$100.80
Rate for Payer: Medicaid All Medicaid	$103.04
Rate for Payer: Medicare All Medicare	$78.40
Rate for Payer: Monida Allegiance	$106.40
Rate for Payer: Monida First Choice Health	$108.64
Rate for Payer: Monida Montana Health Co-op	$106.40
Rate for Payer: Monida PacificSource	$106.40

ePHEDrine INJ [50 MG/ML]

Facility

$112.00

Service Code	HCPCS J3490
Hospital Charge Code	3000143
Hospital Revenue Code	250
Min. Negotiated Rate	$78.40
Max. Negotiated Rate	$112.00
Rate for Payer: Aetna Commercial	$106.40
Rate for Payer: Aetna Medicare	$100.80
Rate for Payer: BCBS MT CHIP	$100.80
Rate for Payer: BCBS MT Closed Plan Network	$106.40
Rate for Payer: BCBS MT HealthLink	$100.80
Rate for Payer: BCBS MT Medicare	$100.80
Rate for Payer: BCBS MT POS	$106.40
Rate for Payer: BCBS MT Traditional	$112.00
Rate for Payer: Cash Price	$100.80
Rate for Payer: Cigna Commercial	$106.40
Rate for Payer: Cigna Medicare	$100.80
Rate for Payer: Medicaid All Medicaid	$103.04
Rate for Payer: Medicare All Medicare	$78.40
Rate for Payer: Monida Allegiance	$106.40
Rate for Payer: Monida First Choice Health	$108.64
Rate for Payer: Monida Montana Health Co-op	$106.40
Rate for Payer: Monida PacificSource	$106.40

EPINEPHRINE HCL INJ PEN [0.15 MG]

Facility

$571.00

Service Code	HCPCS J0171
Hospital Charge Code	3000145
Hospital Revenue Code	250
Min. Negotiated Rate	$399.70
Max. Negotiated Rate	$571.00
Rate for Payer: Aetna Commercial	$542.45
Rate for Payer: Aetna Medicare	$513.90
Rate for Payer: BCBS MT CHIP	$513.90
Rate for Payer: BCBS MT Closed Plan Network	$542.45
Rate for Payer: BCBS MT HealthLink	$513.90
Rate for Payer: BCBS MT Medicare	$513.90
Rate for Payer: BCBS MT POS	$542.45
Rate for Payer: BCBS MT Traditional	$571.00
Rate for Payer: Cash Price	$513.90
Rate for Payer: Cigna Commercial	$542.45
Rate for Payer: Cigna Medicare	$513.90
Rate for Payer: Medicaid All Medicaid	$525.32
Rate for Payer: Medicare All Medicare	$399.70
Rate for Payer: Monida Allegiance	$542.45
Rate for Payer: Monida First Choice Health	$553.87
Rate for Payer: Monida Montana Health Co-op	$542.45
Rate for Payer: Monida PacificSource	$542.45

EPINEPHRINE HCL INJ PEN [0.15 MG]

Facility

$571.00

Service Code	HCPCS J0171
Hospital Charge Code	3000145
Hospital Revenue Code	250
Min. Negotiated Rate	$399.70
Max. Negotiated Rate	$571.00
Rate for Payer: Aetna Commercial	$542.45
Rate for Payer: Aetna Medicare	$513.90
Rate for Payer: BCBS MT CHIP	$513.90
Rate for Payer: BCBS MT Closed Plan Network	$542.45
Rate for Payer: BCBS MT HealthLink	$513.90
Rate for Payer: BCBS MT Medicare	$513.90
Rate for Payer: BCBS MT POS	$542.45
Rate for Payer: BCBS MT Traditional	$571.00
Rate for Payer: Cash Price	$513.90
Rate for Payer: Cigna Commercial	$542.45
Rate for Payer: Cigna Medicare	$513.90
Rate for Payer: Medicaid All Medicaid	$525.32
Rate for Payer: Medicare All Medicare	$399.70
Rate for Payer: Monida Allegiance	$542.45
Rate for Payer: Monida First Choice Health	$553.87
Rate for Payer: Monida Montana Health Co-op	$542.45
Rate for Payer: Monida PacificSource	$542.45

EPINEPHRINE HCL INJ PEN [0.3 MG]

Facility

$571.00

Service Code	HCPCS J0171
Hospital Charge Code	3000146
Hospital Revenue Code	259
Min. Negotiated Rate	$399.70
Max. Negotiated Rate	$571.00
Rate for Payer: Aetna Commercial	$542.45
Rate for Payer: Aetna Medicare	$513.90
Rate for Payer: BCBS MT CHIP	$513.90
Rate for Payer: BCBS MT Closed Plan Network	$542.45
Rate for Payer: BCBS MT HealthLink	$513.90
Rate for Payer: BCBS MT Medicare	$513.90
Rate for Payer: BCBS MT POS	$542.45
Rate for Payer: BCBS MT Traditional	$571.00
Rate for Payer: Cash Price	$513.90
Rate for Payer: Cigna Commercial	$542.45
Rate for Payer: Cigna Medicare	$513.90
Rate for Payer: Medicaid All Medicaid	$525.32
Rate for Payer: Medicare All Medicare	$399.70
Rate for Payer: Monida Allegiance	$542.45
Rate for Payer: Monida First Choice Health	$553.87
Rate for Payer: Monida Montana Health Co-op	$542.45
Rate for Payer: Monida PacificSource	$542.45

EPINEPHRINE HCL INJ PEN [0.3 MG]

Facility

$571.00

Service Code	HCPCS J0171
Hospital Charge Code	3000146
Hospital Revenue Code	259
Min. Negotiated Rate	$399.70
Max. Negotiated Rate	$571.00
Rate for Payer: Aetna Commercial	$542.45
Rate for Payer: Aetna Medicare	$513.90
Rate for Payer: BCBS MT CHIP	$513.90
Rate for Payer: BCBS MT Closed Plan Network	$542.45
Rate for Payer: BCBS MT HealthLink	$513.90
Rate for Payer: BCBS MT Medicare	$513.90
Rate for Payer: BCBS MT POS	$542.45
Rate for Payer: BCBS MT Traditional	$571.00
Rate for Payer: Cash Price	$513.90
Rate for Payer: Cigna Commercial	$542.45
Rate for Payer: Cigna Medicare	$513.90
Rate for Payer: Medicaid All Medicaid	$525.32
Rate for Payer: Medicare All Medicare	$399.70
Rate for Payer: Monida Allegiance	$542.45
Rate for Payer: Monida First Choice Health	$553.87
Rate for Payer: Monida Montana Health Co-op	$542.45
Rate for Payer: Monida PacificSource	$542.45

EPINEPHRINE INJ [1 MG/ML] SDV

Facility

$56.00

Service Code	HCPCS J0171
Hospital Charge Code	3000147
Hospital Revenue Code	259
Min. Negotiated Rate	$39.20
Max. Negotiated Rate	$56.00
Rate for Payer: Aetna Commercial	$53.20
Rate for Payer: Aetna Medicare	$50.40
Rate for Payer: BCBS MT CHIP	$50.40
Rate for Payer: BCBS MT Closed Plan Network	$53.20
Rate for Payer: BCBS MT HealthLink	$50.40
Rate for Payer: BCBS MT Medicare	$50.40
Rate for Payer: BCBS MT POS	$53.20
Rate for Payer: BCBS MT Traditional	$56.00
Rate for Payer: Cash Price	$50.40
Rate for Payer: Cigna Commercial	$53.20
Rate for Payer: Cigna Medicare	$50.40
Rate for Payer: Medicaid All Medicaid	$51.52
Rate for Payer: Medicare All Medicare	$39.20
Rate for Payer: Monida Allegiance	$53.20
Rate for Payer: Monida First Choice Health	$54.32
Rate for Payer: Monida Montana Health Co-op	$53.20
Rate for Payer: Monida PacificSource	$53.20

EPINEPHRINE INJ [1 MG/ML] SDV

Facility

$56.00

Service Code	HCPCS J0171
Hospital Charge Code	3000147
Hospital Revenue Code	259
Min. Negotiated Rate	$39.20
Max. Negotiated Rate	$56.00
Rate for Payer: Aetna Commercial	$53.20
Rate for Payer: Aetna Medicare	$50.40
Rate for Payer: BCBS MT CHIP	$50.40
Rate for Payer: BCBS MT Closed Plan Network	$53.20
Rate for Payer: BCBS MT HealthLink	$50.40
Rate for Payer: BCBS MT Medicare	$50.40
Rate for Payer: BCBS MT POS	$53.20
Rate for Payer: BCBS MT Traditional	$56.00
Rate for Payer: Cash Price	$50.40
Rate for Payer: Cigna Commercial	$53.20
Rate for Payer: Cigna Medicare	$50.40
Rate for Payer: Medicaid All Medicaid	$51.52
Rate for Payer: Medicare All Medicare	$39.20
Rate for Payer: Monida Allegiance	$53.20
Rate for Payer: Monida First Choice Health	$54.32
Rate for Payer: Monida Montana Health Co-op	$53.20
Rate for Payer: Monida PacificSource	$53.20

EPINEPHRINE INJ SYR [1 MG/10 ML]

Facility

$26.00

Service Code	HCPCS J0171
Hospital Charge Code	3000148
Hospital Revenue Code	259
Min. Negotiated Rate	$18.20
Max. Negotiated Rate	$26.00
Rate for Payer: Aetna Commercial	$24.70
Rate for Payer: Aetna Medicare	$23.40
Rate for Payer: BCBS MT CHIP	$23.40
Rate for Payer: BCBS MT Closed Plan Network	$24.70
Rate for Payer: BCBS MT HealthLink	$23.40
Rate for Payer: BCBS MT Medicare	$23.40
Rate for Payer: BCBS MT POS	$24.70
Rate for Payer: BCBS MT Traditional	$26.00
Rate for Payer: Cash Price	$23.40
Rate for Payer: Cigna Commercial	$24.70
Rate for Payer: Cigna Medicare	$23.40
Rate for Payer: Medicaid All Medicaid	$23.92
Rate for Payer: Medicare All Medicare	$18.20
Rate for Payer: Monida Allegiance	$24.70
Rate for Payer: Monida First Choice Health	$25.22
Rate for Payer: Monida Montana Health Co-op	$24.70
Rate for Payer: Monida PacificSource	$24.70

EPINEPHRINE INJ SYR [1 MG/10 ML]

Facility

$26.00

Service Code	HCPCS J0171
Hospital Charge Code	3000148
Hospital Revenue Code	259
Min. Negotiated Rate	$18.20
Max. Negotiated Rate	$26.00
Rate for Payer: Aetna Commercial	$24.70
Rate for Payer: Aetna Medicare	$23.40
Rate for Payer: BCBS MT CHIP	$23.40
Rate for Payer: BCBS MT Closed Plan Network	$24.70
Rate for Payer: BCBS MT HealthLink	$23.40
Rate for Payer: BCBS MT Medicare	$23.40
Rate for Payer: BCBS MT POS	$24.70
Rate for Payer: BCBS MT Traditional	$26.00
Rate for Payer: Cash Price	$23.40
Rate for Payer: Cigna Commercial	$24.70
Rate for Payer: Cigna Medicare	$23.40
Rate for Payer: Medicaid All Medicaid	$23.92
Rate for Payer: Medicare All Medicare	$18.20
Rate for Payer: Monida Allegiance	$24.70
Rate for Payer: Monida First Choice Health	$25.22
Rate for Payer: Monida Montana Health Co-op	$24.70
Rate for Payer: Monida PacificSource	$24.70

EPISTAXIS COMPLEX- ER

Facility

$461.00

Service Code	HCPCS 30903
Hospital Charge Code	1030903
Hospital Revenue Code	450
Min. Negotiated Rate	$322.70
Max. Negotiated Rate	$461.00
Rate for Payer: Aetna Commercial	$437.95
Rate for Payer: Aetna Medicare	$414.90
Rate for Payer: BCBS MT CHIP	$414.90
Rate for Payer: BCBS MT Closed Plan Network	$437.95
Rate for Payer: BCBS MT HealthLink	$414.90
Rate for Payer: BCBS MT Medicare	$414.90
Rate for Payer: BCBS MT POS	$437.95
Rate for Payer: BCBS MT Traditional	$461.00
Rate for Payer: Cash Price	$414.90
Rate for Payer: Cigna Commercial	$437.95
Rate for Payer: Cigna Medicare	$414.90
Rate for Payer: Medicaid All Medicaid	$424.12
Rate for Payer: Medicare All Medicare	$322.70
Rate for Payer: Monida Allegiance	$437.95
Rate for Payer: Monida First Choice Health	$447.17
Rate for Payer: Monida Montana Health Co-op	$437.95
Rate for Payer: Monida PacificSource	$437.95

EPISTAXIS COMPLEX- ER

Facility

$461.00

Service Code	HCPCS 30903
Hospital Charge Code	1030903
Hospital Revenue Code	450
Min. Negotiated Rate	$322.70
Max. Negotiated Rate	$461.00
Rate for Payer: Aetna Commercial	$437.95
Rate for Payer: Aetna Medicare	$414.90
Rate for Payer: BCBS MT CHIP	$414.90
Rate for Payer: BCBS MT Closed Plan Network	$437.95
Rate for Payer: BCBS MT HealthLink	$414.90
Rate for Payer: BCBS MT Medicare	$414.90
Rate for Payer: BCBS MT POS	$437.95
Rate for Payer: BCBS MT Traditional	$461.00
Rate for Payer: Cash Price	$414.90
Rate for Payer: Cigna Commercial	$437.95
Rate for Payer: Cigna Medicare	$414.90
Rate for Payer: Medicaid All Medicaid	$424.12
Rate for Payer: Medicare All Medicare	$322.70
Rate for Payer: Monida Allegiance	$437.95
Rate for Payer: Monida First Choice Health	$447.17
Rate for Payer: Monida Montana Health Co-op	$437.95
Rate for Payer: Monida PacificSource	$437.95

EPISTAXIS INITIAL- ER

Facility

$337.00

Service Code	HCPCS 30905
Hospital Charge Code	1030905
Hospital Revenue Code	450
Min. Negotiated Rate	$235.90
Max. Negotiated Rate	$337.00
Rate for Payer: Aetna Commercial	$320.15
Rate for Payer: Aetna Medicare	$303.30
Rate for Payer: BCBS MT CHIP	$303.30
Rate for Payer: BCBS MT Closed Plan Network	$320.15
Rate for Payer: BCBS MT HealthLink	$303.30
Rate for Payer: BCBS MT Medicare	$303.30
Rate for Payer: BCBS MT POS	$320.15
Rate for Payer: BCBS MT Traditional	$337.00
Rate for Payer: Cash Price	$303.30
Rate for Payer: Cigna Commercial	$320.15
Rate for Payer: Cigna Medicare	$303.30
Rate for Payer: Medicaid All Medicaid	$310.04
Rate for Payer: Medicare All Medicare	$235.90
Rate for Payer: Monida Allegiance	$320.15
Rate for Payer: Monida First Choice Health	$326.89
Rate for Payer: Monida Montana Health Co-op	$320.15
Rate for Payer: Monida PacificSource	$320.15

EPISTAXIS INITIAL- ER

Facility

$337.00

Service Code	HCPCS 30905
Hospital Charge Code	1030905
Hospital Revenue Code	450
Min. Negotiated Rate	$235.90
Max. Negotiated Rate	$337.00
Rate for Payer: Aetna Commercial	$320.15
Rate for Payer: Aetna Medicare	$303.30
Rate for Payer: BCBS MT CHIP	$303.30
Rate for Payer: BCBS MT Closed Plan Network	$320.15
Rate for Payer: BCBS MT HealthLink	$303.30
Rate for Payer: BCBS MT Medicare	$303.30
Rate for Payer: BCBS MT POS	$320.15
Rate for Payer: BCBS MT Traditional	$337.00
Rate for Payer: Cash Price	$303.30
Rate for Payer: Cigna Commercial	$320.15
Rate for Payer: Cigna Medicare	$303.30
Rate for Payer: Medicaid All Medicaid	$310.04
Rate for Payer: Medicare All Medicare	$235.90
Rate for Payer: Monida Allegiance	$320.15
Rate for Payer: Monida First Choice Health	$326.89
Rate for Payer: Monida Montana Health Co-op	$320.15
Rate for Payer: Monida PacificSource	$320.15

EPISTAXIS SIMPLE- ER

Facility

$308.00

Service Code	HCPCS 30901
Hospital Charge Code	1030901
Hospital Revenue Code	450
Min. Negotiated Rate	$215.60
Max. Negotiated Rate	$308.00
Rate for Payer: Aetna Commercial	$292.60
Rate for Payer: Aetna Medicare	$277.20
Rate for Payer: BCBS MT CHIP	$277.20
Rate for Payer: BCBS MT Closed Plan Network	$292.60
Rate for Payer: BCBS MT HealthLink	$277.20
Rate for Payer: BCBS MT Medicare	$277.20
Rate for Payer: BCBS MT POS	$292.60
Rate for Payer: BCBS MT Traditional	$308.00
Rate for Payer: Cash Price	$277.20
Rate for Payer: Cigna Commercial	$292.60
Rate for Payer: Cigna Medicare	$277.20
Rate for Payer: Medicaid All Medicaid	$283.36
Rate for Payer: Medicare All Medicare	$215.60
Rate for Payer: Monida Allegiance	$292.60
Rate for Payer: Monida First Choice Health	$298.76
Rate for Payer: Monida Montana Health Co-op	$292.60
Rate for Payer: Monida PacificSource	$292.60

EPISTAXIS SIMPLE- ER

Facility

$308.00

Service Code	HCPCS 30901
Hospital Charge Code	1030901
Hospital Revenue Code	450
Min. Negotiated Rate	$215.60
Max. Negotiated Rate	$308.00
Rate for Payer: Aetna Commercial	$292.60
Rate for Payer: Aetna Medicare	$277.20
Rate for Payer: BCBS MT CHIP	$277.20
Rate for Payer: BCBS MT Closed Plan Network	$292.60
Rate for Payer: BCBS MT HealthLink	$277.20
Rate for Payer: BCBS MT Medicare	$277.20
Rate for Payer: BCBS MT POS	$292.60
Rate for Payer: BCBS MT Traditional	$308.00
Rate for Payer: Cash Price	$277.20
Rate for Payer: Cigna Commercial	$292.60
Rate for Payer: Cigna Medicare	$277.20
Rate for Payer: Medicaid All Medicaid	$283.36
Rate for Payer: Medicare All Medicare	$215.60
Rate for Payer: Monida Allegiance	$292.60
Rate for Payer: Monida First Choice Health	$298.76
Rate for Payer: Monida Montana Health Co-op	$292.60
Rate for Payer: Monida PacificSource	$292.60

EPOETIN ALFA INJ [10,000 U/ML] SPEC ORD

Facility

$640.00

Service Code	HCPCS J0885
Hospital Charge Code	3000149
Hospital Revenue Code	259
Min. Negotiated Rate	$448.00
Max. Negotiated Rate	$640.00
Rate for Payer: Aetna Commercial	$608.00
Rate for Payer: Aetna Medicare	$576.00
Rate for Payer: BCBS MT CHIP	$576.00
Rate for Payer: BCBS MT Closed Plan Network	$608.00
Rate for Payer: BCBS MT HealthLink	$576.00
Rate for Payer: BCBS MT Medicare	$576.00
Rate for Payer: BCBS MT POS	$608.00
Rate for Payer: BCBS MT Traditional	$640.00
Rate for Payer: Cash Price	$576.00
Rate for Payer: Cigna Commercial	$608.00
Rate for Payer: Cigna Medicare	$576.00
Rate for Payer: Medicaid All Medicaid	$588.80
Rate for Payer: Medicare All Medicare	$448.00
Rate for Payer: Monida Allegiance	$608.00
Rate for Payer: Monida First Choice Health	$620.80
Rate for Payer: Monida Montana Health Co-op	$608.00
Rate for Payer: Monida PacificSource	$608.00

EPOETIN ALFA INJ [10,000 U/ML] SPEC ORD

Facility

$640.00

Service Code	HCPCS J0885
Hospital Charge Code	3000149
Hospital Revenue Code	259
Min. Negotiated Rate	$448.00
Max. Negotiated Rate	$640.00
Rate for Payer: Aetna Commercial	$608.00
Rate for Payer: Aetna Medicare	$576.00
Rate for Payer: BCBS MT CHIP	$576.00
Rate for Payer: BCBS MT Closed Plan Network	$608.00
Rate for Payer: BCBS MT HealthLink	$576.00
Rate for Payer: BCBS MT Medicare	$576.00
Rate for Payer: BCBS MT POS	$608.00
Rate for Payer: BCBS MT Traditional	$640.00
Rate for Payer: Cash Price	$576.00
Rate for Payer: Cigna Commercial	$608.00
Rate for Payer: Cigna Medicare	$576.00
Rate for Payer: Medicaid All Medicaid	$588.80
Rate for Payer: Medicare All Medicare	$448.00
Rate for Payer: Monida Allegiance	$608.00
Rate for Payer: Monida First Choice Health	$620.80
Rate for Payer: Monida Montana Health Co-op	$608.00
Rate for Payer: Monida PacificSource	$608.00

ER APPLICATION OF FINGER SPLINT; DYNAMIC

Facility

$173.00

Service Code	HCPCS 29131
Hospital Charge Code	1029131
Hospital Revenue Code	450
Min. Negotiated Rate	$121.10
Max. Negotiated Rate	$173.00
Rate for Payer: Aetna Commercial	$164.35
Rate for Payer: Aetna Medicare	$155.70
Rate for Payer: BCBS MT CHIP	$155.70
Rate for Payer: BCBS MT Closed Plan Network	$164.35
Rate for Payer: BCBS MT HealthLink	$155.70
Rate for Payer: BCBS MT Medicare	$155.70
Rate for Payer: BCBS MT POS	$164.35
Rate for Payer: BCBS MT Traditional	$173.00
Rate for Payer: Cash Price	$155.70
Rate for Payer: Cigna Commercial	$164.35
Rate for Payer: Cigna Medicare	$155.70
Rate for Payer: Medicaid All Medicaid	$159.16
Rate for Payer: Medicare All Medicare	$121.10
Rate for Payer: Monida Allegiance	$164.35
Rate for Payer: Monida First Choice Health	$167.81
Rate for Payer: Monida Montana Health Co-op	$164.35
Rate for Payer: Monida PacificSource	$164.35

ER APPLICATION OF FINGER SPLINT; DYNAMIC

Facility

$173.00

Service Code	HCPCS 29131
Hospital Charge Code	1029131
Hospital Revenue Code	450
Min. Negotiated Rate	$121.10
Max. Negotiated Rate	$173.00
Rate for Payer: Aetna Commercial	$164.35
Rate for Payer: Aetna Medicare	$155.70
Rate for Payer: BCBS MT CHIP	$155.70
Rate for Payer: BCBS MT Closed Plan Network	$164.35
Rate for Payer: BCBS MT HealthLink	$155.70
Rate for Payer: BCBS MT Medicare	$155.70
Rate for Payer: BCBS MT POS	$164.35
Rate for Payer: BCBS MT Traditional	$173.00
Rate for Payer: Cash Price	$155.70
Rate for Payer: Cigna Commercial	$164.35
Rate for Payer: Cigna Medicare	$155.70
Rate for Payer: Medicaid All Medicaid	$159.16
Rate for Payer: Medicare All Medicare	$121.10
Rate for Payer: Monida Allegiance	$164.35
Rate for Payer: Monida First Choice Health	$167.81
Rate for Payer: Monida Montana Health Co-op	$164.35
Rate for Payer: Monida PacificSource	$164.35

ER APPLICATION OF FOREARM CAST

Facility

$268.00

Service Code	HCPCS 29075
Hospital Charge Code	1029075
Hospital Revenue Code	450
Min. Negotiated Rate	$187.60
Max. Negotiated Rate	$268.00
Rate for Payer: Aetna Commercial	$254.60
Rate for Payer: Aetna Medicare	$241.20
Rate for Payer: BCBS MT CHIP	$241.20
Rate for Payer: BCBS MT Closed Plan Network	$254.60
Rate for Payer: BCBS MT HealthLink	$241.20
Rate for Payer: BCBS MT Medicare	$241.20
Rate for Payer: BCBS MT POS	$254.60
Rate for Payer: BCBS MT Traditional	$268.00
Rate for Payer: Cash Price	$241.20
Rate for Payer: Cigna Commercial	$254.60
Rate for Payer: Cigna Medicare	$241.20
Rate for Payer: Medicaid All Medicaid	$246.56
Rate for Payer: Medicare All Medicare	$187.60
Rate for Payer: Monida Allegiance	$254.60
Rate for Payer: Monida First Choice Health	$259.96
Rate for Payer: Monida Montana Health Co-op	$254.60
Rate for Payer: Monida PacificSource	$254.60

ER APPLICATION OF FOREARM CAST

Facility

$268.00

Service Code	HCPCS 29075
Hospital Charge Code	1029075
Hospital Revenue Code	450
Min. Negotiated Rate	$187.60
Max. Negotiated Rate	$268.00
Rate for Payer: Aetna Commercial	$254.60
Rate for Payer: Aetna Medicare	$241.20
Rate for Payer: BCBS MT CHIP	$241.20
Rate for Payer: BCBS MT Closed Plan Network	$254.60
Rate for Payer: BCBS MT HealthLink	$241.20
Rate for Payer: BCBS MT Medicare	$241.20
Rate for Payer: BCBS MT POS	$254.60
Rate for Payer: BCBS MT Traditional	$268.00
Rate for Payer: Cash Price	$241.20
Rate for Payer: Cigna Commercial	$254.60
Rate for Payer: Cigna Medicare	$241.20
Rate for Payer: Medicaid All Medicaid	$246.56
Rate for Payer: Medicare All Medicare	$187.60
Rate for Payer: Monida Allegiance	$254.60
Rate for Payer: Monida First Choice Health	$259.96
Rate for Payer: Monida Montana Health Co-op	$254.60
Rate for Payer: Monida PacificSource	$254.60

ER APPLICATION SPLING TO ANKLE/AND OR FO

Facility

$169.00

Service Code	HCPCS 29540
Hospital Charge Code	1029540
Hospital Revenue Code	450
Min. Negotiated Rate	$118.30
Max. Negotiated Rate	$169.00
Rate for Payer: Aetna Commercial	$160.55
Rate for Payer: Aetna Medicare	$152.10
Rate for Payer: BCBS MT CHIP	$152.10
Rate for Payer: BCBS MT Closed Plan Network	$160.55
Rate for Payer: BCBS MT HealthLink	$152.10
Rate for Payer: BCBS MT Medicare	$152.10
Rate for Payer: BCBS MT POS	$160.55
Rate for Payer: BCBS MT Traditional	$169.00
Rate for Payer: Cash Price	$152.10
Rate for Payer: Cigna Commercial	$160.55
Rate for Payer: Cigna Medicare	$152.10
Rate for Payer: Medicaid All Medicaid	$155.48
Rate for Payer: Medicare All Medicare	$118.30
Rate for Payer: Monida Allegiance	$160.55
Rate for Payer: Monida First Choice Health	$163.93
Rate for Payer: Monida Montana Health Co-op	$160.55
Rate for Payer: Monida PacificSource	$160.55

Know your out-of-pocket cost for care.

All Charges