Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

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

ER APPLICATION SPLINT ARM SHORT

Facility

$311.00

Service Code	HCPCS 29125
Hospital Charge Code	1029125
Hospital Revenue Code	450
Min. Negotiated Rate	$217.70
Max. Negotiated Rate	$311.00
Rate for Payer: Aetna Commercial	$295.45
Rate for Payer: Aetna Medicare	$279.90
Rate for Payer: BCBS MT CHIP	$279.90
Rate for Payer: BCBS MT Closed Plan Network	$295.45
Rate for Payer: BCBS MT HealthLink	$279.90
Rate for Payer: BCBS MT Medicare	$279.90
Rate for Payer: BCBS MT POS	$295.45
Rate for Payer: BCBS MT Traditional	$311.00
Rate for Payer: Cash Price	$279.90
Rate for Payer: Cigna Commercial	$295.45
Rate for Payer: Cigna Medicare	$279.90
Rate for Payer: Medicaid All Medicaid	$286.12
Rate for Payer: Medicare All Medicare	$217.70
Rate for Payer: Monida Allegiance	$295.45
Rate for Payer: Monida First Choice Health	$301.67
Rate for Payer: Monida Montana Health Co-op	$295.45
Rate for Payer: Monida PacificSource	$295.45

ER APPLICATION SPLINT ARM SHORT

Facility

$311.00

Service Code	HCPCS 29125
Hospital Charge Code	1029125
Hospital Revenue Code	450
Min. Negotiated Rate	$217.70
Max. Negotiated Rate	$311.00
Rate for Payer: Aetna Commercial	$295.45
Rate for Payer: Aetna Medicare	$279.90
Rate for Payer: BCBS MT CHIP	$279.90
Rate for Payer: BCBS MT Closed Plan Network	$295.45
Rate for Payer: BCBS MT HealthLink	$279.90
Rate for Payer: BCBS MT Medicare	$279.90
Rate for Payer: BCBS MT POS	$295.45
Rate for Payer: BCBS MT Traditional	$311.00
Rate for Payer: Cash Price	$279.90
Rate for Payer: Cigna Commercial	$295.45
Rate for Payer: Cigna Medicare	$279.90
Rate for Payer: Medicaid All Medicaid	$286.12
Rate for Payer: Medicare All Medicare	$217.70
Rate for Payer: Monida Allegiance	$295.45
Rate for Payer: Monida First Choice Health	$301.67
Rate for Payer: Monida Montana Health Co-op	$295.45
Rate for Payer: Monida PacificSource	$295.45

ER APPLICATION SPLINT FINGER STATIC

Facility

$235.00

Service Code	HCPCS 29130
Hospital Charge Code	1029130
Hospital Revenue Code	450
Min. Negotiated Rate	$164.50
Max. Negotiated Rate	$235.00
Rate for Payer: Aetna Commercial	$223.25
Rate for Payer: Aetna Medicare	$211.50
Rate for Payer: BCBS MT CHIP	$211.50
Rate for Payer: BCBS MT Closed Plan Network	$223.25
Rate for Payer: BCBS MT HealthLink	$211.50
Rate for Payer: BCBS MT Medicare	$211.50
Rate for Payer: BCBS MT POS	$223.25
Rate for Payer: BCBS MT Traditional	$235.00
Rate for Payer: Cash Price	$211.50
Rate for Payer: Cigna Commercial	$223.25
Rate for Payer: Cigna Medicare	$211.50
Rate for Payer: Medicaid All Medicaid	$216.20
Rate for Payer: Medicare All Medicare	$164.50
Rate for Payer: Monida Allegiance	$223.25
Rate for Payer: Monida First Choice Health	$227.95
Rate for Payer: Monida Montana Health Co-op	$223.25
Rate for Payer: Monida PacificSource	$223.25

ER APPLICATION SPLINT FINGER STATIC

Facility

$235.00

Service Code	HCPCS 29130
Hospital Charge Code	1029130
Hospital Revenue Code	450
Min. Negotiated Rate	$164.50
Max. Negotiated Rate	$235.00
Rate for Payer: Aetna Commercial	$223.25
Rate for Payer: Aetna Medicare	$211.50
Rate for Payer: BCBS MT CHIP	$211.50
Rate for Payer: BCBS MT Closed Plan Network	$223.25
Rate for Payer: BCBS MT HealthLink	$211.50
Rate for Payer: BCBS MT Medicare	$211.50
Rate for Payer: BCBS MT POS	$223.25
Rate for Payer: BCBS MT Traditional	$235.00
Rate for Payer: Cash Price	$211.50
Rate for Payer: Cigna Commercial	$223.25
Rate for Payer: Cigna Medicare	$211.50
Rate for Payer: Medicaid All Medicaid	$216.20
Rate for Payer: Medicare All Medicare	$164.50
Rate for Payer: Monida Allegiance	$223.25
Rate for Payer: Monida First Choice Health	$227.95
Rate for Payer: Monida Montana Health Co-op	$223.25
Rate for Payer: Monida PacificSource	$223.25

ER APPLICATION SPLINT HAND OR FINGER

Facility

$181.00

Service Code	HCPCS 29280
Hospital Charge Code	1029280
Hospital Revenue Code	450
Min. Negotiated Rate	$126.70
Max. Negotiated Rate	$181.00
Rate for Payer: Aetna Commercial	$171.95
Rate for Payer: Aetna Medicare	$162.90
Rate for Payer: BCBS MT CHIP	$162.90
Rate for Payer: BCBS MT Closed Plan Network	$171.95
Rate for Payer: BCBS MT HealthLink	$162.90
Rate for Payer: BCBS MT Medicare	$162.90
Rate for Payer: BCBS MT POS	$171.95
Rate for Payer: BCBS MT Traditional	$181.00
Rate for Payer: Cash Price	$162.90
Rate for Payer: Cigna Commercial	$171.95
Rate for Payer: Cigna Medicare	$162.90
Rate for Payer: Medicaid All Medicaid	$166.52
Rate for Payer: Medicare All Medicare	$126.70
Rate for Payer: Monida Allegiance	$171.95
Rate for Payer: Monida First Choice Health	$175.57
Rate for Payer: Monida Montana Health Co-op	$171.95
Rate for Payer: Monida PacificSource	$171.95

ER APPLICATION SPLINT HAND OR FINGER

Facility

$181.00

Service Code	HCPCS 29280
Hospital Charge Code	1029280
Hospital Revenue Code	450
Min. Negotiated Rate	$126.70
Max. Negotiated Rate	$181.00
Rate for Payer: Aetna Commercial	$171.95
Rate for Payer: Aetna Medicare	$162.90
Rate for Payer: BCBS MT CHIP	$162.90
Rate for Payer: BCBS MT Closed Plan Network	$171.95
Rate for Payer: BCBS MT HealthLink	$162.90
Rate for Payer: BCBS MT Medicare	$162.90
Rate for Payer: BCBS MT POS	$171.95
Rate for Payer: BCBS MT Traditional	$181.00
Rate for Payer: Cash Price	$162.90
Rate for Payer: Cigna Commercial	$171.95
Rate for Payer: Cigna Medicare	$162.90
Rate for Payer: Medicaid All Medicaid	$166.52
Rate for Payer: Medicare All Medicare	$126.70
Rate for Payer: Monida Allegiance	$171.95
Rate for Payer: Monida First Choice Health	$175.57
Rate for Payer: Monida Montana Health Co-op	$171.95
Rate for Payer: Monida PacificSource	$171.95

ER APPLICATION SPLINT LEG LONG

Facility

$328.00

Service Code	HCPCS 29505
Hospital Charge Code	1029505
Hospital Revenue Code	450
Min. Negotiated Rate	$229.60
Max. Negotiated Rate	$328.00
Rate for Payer: Aetna Commercial	$311.60
Rate for Payer: Aetna Medicare	$295.20
Rate for Payer: BCBS MT CHIP	$295.20
Rate for Payer: BCBS MT Closed Plan Network	$311.60
Rate for Payer: BCBS MT HealthLink	$295.20
Rate for Payer: BCBS MT Medicare	$295.20
Rate for Payer: BCBS MT POS	$311.60
Rate for Payer: BCBS MT Traditional	$328.00
Rate for Payer: Cash Price	$295.20
Rate for Payer: Cigna Commercial	$311.60
Rate for Payer: Cigna Medicare	$295.20
Rate for Payer: Medicaid All Medicaid	$301.76
Rate for Payer: Medicare All Medicare	$229.60
Rate for Payer: Monida Allegiance	$311.60
Rate for Payer: Monida First Choice Health	$318.16
Rate for Payer: Monida Montana Health Co-op	$311.60
Rate for Payer: Monida PacificSource	$311.60

ER APPLICATION SPLINT LEG LONG

Facility

$328.00

Service Code	HCPCS 29505
Hospital Charge Code	1029505
Hospital Revenue Code	450
Min. Negotiated Rate	$229.60
Max. Negotiated Rate	$328.00
Rate for Payer: Aetna Commercial	$311.60
Rate for Payer: Aetna Medicare	$295.20
Rate for Payer: BCBS MT CHIP	$295.20
Rate for Payer: BCBS MT Closed Plan Network	$311.60
Rate for Payer: BCBS MT HealthLink	$295.20
Rate for Payer: BCBS MT Medicare	$295.20
Rate for Payer: BCBS MT POS	$311.60
Rate for Payer: BCBS MT Traditional	$328.00
Rate for Payer: Cash Price	$295.20
Rate for Payer: Cigna Commercial	$311.60
Rate for Payer: Cigna Medicare	$295.20
Rate for Payer: Medicaid All Medicaid	$301.76
Rate for Payer: Medicare All Medicare	$229.60
Rate for Payer: Monida Allegiance	$311.60
Rate for Payer: Monida First Choice Health	$318.16
Rate for Payer: Monida Montana Health Co-op	$311.60
Rate for Payer: Monida PacificSource	$311.60

ER APPLICATION SPLINT LONG

Facility

$345.00

Service Code	HCPCS 29105
Hospital Charge Code	1029105
Hospital Revenue Code	450
Min. Negotiated Rate	$241.50
Max. Negotiated Rate	$345.00
Rate for Payer: Aetna Commercial	$327.75
Rate for Payer: Aetna Medicare	$310.50
Rate for Payer: BCBS MT CHIP	$310.50
Rate for Payer: BCBS MT Closed Plan Network	$327.75
Rate for Payer: BCBS MT HealthLink	$310.50
Rate for Payer: BCBS MT Medicare	$310.50
Rate for Payer: BCBS MT POS	$327.75
Rate for Payer: BCBS MT Traditional	$345.00
Rate for Payer: Cash Price	$310.50
Rate for Payer: Cigna Commercial	$327.75
Rate for Payer: Cigna Medicare	$310.50
Rate for Payer: Medicaid All Medicaid	$317.40
Rate for Payer: Medicare All Medicare	$241.50
Rate for Payer: Monida Allegiance	$327.75
Rate for Payer: Monida First Choice Health	$334.65
Rate for Payer: Monida Montana Health Co-op	$327.75
Rate for Payer: Monida PacificSource	$327.75

ER APPLICATION SPLINT LONG

Facility

$345.00

Service Code	HCPCS 29105
Hospital Charge Code	1029105
Hospital Revenue Code	450
Min. Negotiated Rate	$241.50
Max. Negotiated Rate	$345.00
Rate for Payer: Aetna Commercial	$327.75
Rate for Payer: Aetna Medicare	$310.50
Rate for Payer: BCBS MT CHIP	$310.50
Rate for Payer: BCBS MT Closed Plan Network	$327.75
Rate for Payer: BCBS MT HealthLink	$310.50
Rate for Payer: BCBS MT Medicare	$310.50
Rate for Payer: BCBS MT POS	$327.75
Rate for Payer: BCBS MT Traditional	$345.00
Rate for Payer: Cash Price	$310.50
Rate for Payer: Cigna Commercial	$327.75
Rate for Payer: Cigna Medicare	$310.50
Rate for Payer: Medicaid All Medicaid	$317.40
Rate for Payer: Medicare All Medicare	$241.50
Rate for Payer: Monida Allegiance	$327.75
Rate for Payer: Monida First Choice Health	$334.65
Rate for Payer: Monida Montana Health Co-op	$327.75
Rate for Payer: Monida PacificSource	$327.75

ER APPLICATION STRAPPING ELBOW OR WRIST

Facility

$191.00

Service Code	HCPCS 29260
Hospital Charge Code	1029260
Hospital Revenue Code	450
Min. Negotiated Rate	$133.70
Max. Negotiated Rate	$191.00
Rate for Payer: Aetna Commercial	$181.45
Rate for Payer: Aetna Medicare	$171.90
Rate for Payer: BCBS MT CHIP	$171.90
Rate for Payer: BCBS MT Closed Plan Network	$181.45
Rate for Payer: BCBS MT HealthLink	$171.90
Rate for Payer: BCBS MT Medicare	$171.90
Rate for Payer: BCBS MT POS	$181.45
Rate for Payer: BCBS MT Traditional	$191.00
Rate for Payer: Cash Price	$171.90
Rate for Payer: Cigna Commercial	$181.45
Rate for Payer: Cigna Medicare	$171.90
Rate for Payer: Medicaid All Medicaid	$175.72
Rate for Payer: Medicare All Medicare	$133.70
Rate for Payer: Monida Allegiance	$181.45
Rate for Payer: Monida First Choice Health	$185.27
Rate for Payer: Monida Montana Health Co-op	$181.45
Rate for Payer: Monida PacificSource	$181.45

ER APPLICATION STRAPPING ELBOW OR WRIST

Facility

$191.00

Service Code	HCPCS 29260
Hospital Charge Code	1029260
Hospital Revenue Code	450
Min. Negotiated Rate	$133.70
Max. Negotiated Rate	$191.00
Rate for Payer: Aetna Commercial	$181.45
Rate for Payer: Aetna Medicare	$171.90
Rate for Payer: BCBS MT CHIP	$171.90
Rate for Payer: BCBS MT Closed Plan Network	$181.45
Rate for Payer: BCBS MT HealthLink	$171.90
Rate for Payer: BCBS MT Medicare	$171.90
Rate for Payer: BCBS MT POS	$181.45
Rate for Payer: BCBS MT Traditional	$191.00
Rate for Payer: Cash Price	$171.90
Rate for Payer: Cigna Commercial	$181.45
Rate for Payer: Cigna Medicare	$171.90
Rate for Payer: Medicaid All Medicaid	$175.72
Rate for Payer: Medicare All Medicare	$133.70
Rate for Payer: Monida Allegiance	$181.45
Rate for Payer: Monida First Choice Health	$185.27
Rate for Payer: Monida Montana Health Co-op	$181.45
Rate for Payer: Monida PacificSource	$181.45

ER APPLICATION STRAPPING SHOULDER

Facility

$307.00

Service Code	HCPCS 29240
Hospital Charge Code	1029240
Hospital Revenue Code	450
Min. Negotiated Rate	$214.90
Max. Negotiated Rate	$307.00
Rate for Payer: Aetna Commercial	$291.65
Rate for Payer: Aetna Medicare	$276.30
Rate for Payer: BCBS MT CHIP	$276.30
Rate for Payer: BCBS MT Closed Plan Network	$291.65
Rate for Payer: BCBS MT HealthLink	$276.30
Rate for Payer: BCBS MT Medicare	$276.30
Rate for Payer: BCBS MT POS	$291.65
Rate for Payer: BCBS MT Traditional	$307.00
Rate for Payer: Cash Price	$276.30
Rate for Payer: Cigna Commercial	$291.65
Rate for Payer: Cigna Medicare	$276.30
Rate for Payer: Medicaid All Medicaid	$282.44
Rate for Payer: Medicare All Medicare	$214.90
Rate for Payer: Monida Allegiance	$291.65
Rate for Payer: Monida First Choice Health	$297.79
Rate for Payer: Monida Montana Health Co-op	$291.65
Rate for Payer: Monida PacificSource	$291.65

ER APPLICATION STRAPPING SHOULDER

Facility

$307.00

Service Code	HCPCS 29240
Hospital Charge Code	1029240
Hospital Revenue Code	450
Min. Negotiated Rate	$214.90
Max. Negotiated Rate	$307.00
Rate for Payer: Aetna Commercial	$291.65
Rate for Payer: Aetna Medicare	$276.30
Rate for Payer: BCBS MT CHIP	$276.30
Rate for Payer: BCBS MT Closed Plan Network	$291.65
Rate for Payer: BCBS MT HealthLink	$276.30
Rate for Payer: BCBS MT Medicare	$276.30
Rate for Payer: BCBS MT POS	$291.65
Rate for Payer: BCBS MT Traditional	$307.00
Rate for Payer: Cash Price	$276.30
Rate for Payer: Cigna Commercial	$291.65
Rate for Payer: Cigna Medicare	$276.30
Rate for Payer: Medicaid All Medicaid	$282.44
Rate for Payer: Medicare All Medicare	$214.90
Rate for Payer: Monida Allegiance	$291.65
Rate for Payer: Monida First Choice Health	$297.79
Rate for Payer: Monida Montana Health Co-op	$291.65
Rate for Payer: Monida PacificSource	$291.65

ER APPLY LONG LEG CAST

Facility

$328.00

Service Code	HCPCS 29345
Hospital Charge Code	1029345
Hospital Revenue Code	450
Min. Negotiated Rate	$229.60
Max. Negotiated Rate	$328.00
Rate for Payer: Aetna Commercial	$311.60
Rate for Payer: Aetna Medicare	$295.20
Rate for Payer: BCBS MT CHIP	$295.20
Rate for Payer: BCBS MT Closed Plan Network	$311.60
Rate for Payer: BCBS MT HealthLink	$295.20
Rate for Payer: BCBS MT Medicare	$295.20
Rate for Payer: BCBS MT POS	$311.60
Rate for Payer: BCBS MT Traditional	$328.00
Rate for Payer: Cash Price	$295.20
Rate for Payer: Cigna Commercial	$311.60
Rate for Payer: Cigna Medicare	$295.20
Rate for Payer: Medicaid All Medicaid	$301.76
Rate for Payer: Medicare All Medicare	$229.60
Rate for Payer: Monida Allegiance	$311.60
Rate for Payer: Monida First Choice Health	$318.16
Rate for Payer: Monida Montana Health Co-op	$311.60
Rate for Payer: Monida PacificSource	$311.60

ER APPLY LONG LEG CAST

Facility

$328.00

Service Code	HCPCS 29345
Hospital Charge Code	1029345
Hospital Revenue Code	450
Min. Negotiated Rate	$229.60
Max. Negotiated Rate	$328.00
Rate for Payer: Aetna Commercial	$311.60
Rate for Payer: Aetna Medicare	$295.20
Rate for Payer: BCBS MT CHIP	$295.20
Rate for Payer: BCBS MT Closed Plan Network	$311.60
Rate for Payer: BCBS MT HealthLink	$295.20
Rate for Payer: BCBS MT Medicare	$295.20
Rate for Payer: BCBS MT POS	$311.60
Rate for Payer: BCBS MT Traditional	$328.00
Rate for Payer: Cash Price	$295.20
Rate for Payer: Cigna Commercial	$311.60
Rate for Payer: Cigna Medicare	$295.20
Rate for Payer: Medicaid All Medicaid	$301.76
Rate for Payer: Medicare All Medicare	$229.60
Rate for Payer: Monida Allegiance	$311.60
Rate for Payer: Monida First Choice Health	$318.16
Rate for Payer: Monida Montana Health Co-op	$311.60
Rate for Payer: Monida PacificSource	$311.60

ER APPLY SHORT LEG CAST

Facility

$278.00

Service Code	HCPCS 29405
Hospital Charge Code	1029405
Hospital Revenue Code	450
Min. Negotiated Rate	$194.60
Max. Negotiated Rate	$278.00
Rate for Payer: Aetna Commercial	$264.10
Rate for Payer: Aetna Medicare	$250.20
Rate for Payer: BCBS MT CHIP	$250.20
Rate for Payer: BCBS MT Closed Plan Network	$264.10
Rate for Payer: BCBS MT HealthLink	$250.20
Rate for Payer: BCBS MT Medicare	$250.20
Rate for Payer: BCBS MT POS	$264.10
Rate for Payer: BCBS MT Traditional	$278.00
Rate for Payer: Cash Price	$250.20
Rate for Payer: Cigna Commercial	$264.10
Rate for Payer: Cigna Medicare	$250.20
Rate for Payer: Medicaid All Medicaid	$255.76
Rate for Payer: Medicare All Medicare	$194.60
Rate for Payer: Monida Allegiance	$264.10
Rate for Payer: Monida First Choice Health	$269.66
Rate for Payer: Monida Montana Health Co-op	$264.10
Rate for Payer: Monida PacificSource	$264.10

ER APPLY SHORT LEG CAST

Facility

$278.00

Service Code	HCPCS 29405
Hospital Charge Code	1029405
Hospital Revenue Code	450
Min. Negotiated Rate	$194.60
Max. Negotiated Rate	$278.00
Rate for Payer: Aetna Commercial	$264.10
Rate for Payer: Aetna Medicare	$250.20
Rate for Payer: BCBS MT CHIP	$250.20
Rate for Payer: BCBS MT Closed Plan Network	$264.10
Rate for Payer: BCBS MT HealthLink	$250.20
Rate for Payer: BCBS MT Medicare	$250.20
Rate for Payer: BCBS MT POS	$264.10
Rate for Payer: BCBS MT Traditional	$278.00
Rate for Payer: Cash Price	$250.20
Rate for Payer: Cigna Commercial	$264.10
Rate for Payer: Cigna Medicare	$250.20
Rate for Payer: Medicaid All Medicaid	$255.76
Rate for Payer: Medicare All Medicare	$194.60
Rate for Payer: Monida Allegiance	$264.10
Rate for Payer: Monida First Choice Health	$269.66
Rate for Payer: Monida Montana Health Co-op	$264.10
Rate for Payer: Monida PacificSource	$264.10

ER CARDIOPULMONARY RESUSCITATION

Facility

$825.00

Service Code	HCPCS 92950
Hospital Charge Code	1092950
Hospital Revenue Code	450
Min. Negotiated Rate	$577.50
Max. Negotiated Rate	$825.00
Rate for Payer: Aetna Commercial	$783.75
Rate for Payer: Aetna Medicare	$742.50
Rate for Payer: BCBS MT CHIP	$742.50
Rate for Payer: BCBS MT Closed Plan Network	$783.75
Rate for Payer: BCBS MT HealthLink	$742.50
Rate for Payer: BCBS MT Medicare	$742.50
Rate for Payer: BCBS MT POS	$783.75
Rate for Payer: BCBS MT Traditional	$825.00
Rate for Payer: Cash Price	$742.50
Rate for Payer: Cigna Commercial	$783.75
Rate for Payer: Cigna Medicare	$742.50
Rate for Payer: Medicaid All Medicaid	$759.00
Rate for Payer: Medicare All Medicare	$577.50
Rate for Payer: Monida Allegiance	$783.75
Rate for Payer: Monida First Choice Health	$800.25
Rate for Payer: Monida Montana Health Co-op	$783.75
Rate for Payer: Monida PacificSource	$783.75

ER CARDIOPULMONARY RESUSCITATION

Facility

$825.00

Service Code	HCPCS 92950
Hospital Charge Code	1092950
Hospital Revenue Code	450
Min. Negotiated Rate	$577.50
Max. Negotiated Rate	$825.00
Rate for Payer: Aetna Commercial	$783.75
Rate for Payer: Aetna Medicare	$742.50
Rate for Payer: BCBS MT CHIP	$742.50
Rate for Payer: BCBS MT Closed Plan Network	$783.75
Rate for Payer: BCBS MT HealthLink	$742.50
Rate for Payer: BCBS MT Medicare	$742.50
Rate for Payer: BCBS MT POS	$783.75
Rate for Payer: BCBS MT Traditional	$825.00
Rate for Payer: Cash Price	$742.50
Rate for Payer: Cigna Commercial	$783.75
Rate for Payer: Cigna Medicare	$742.50
Rate for Payer: Medicaid All Medicaid	$759.00
Rate for Payer: Medicare All Medicare	$577.50
Rate for Payer: Monida Allegiance	$783.75
Rate for Payer: Monida First Choice Health	$800.25
Rate for Payer: Monida Montana Health Co-op	$783.75
Rate for Payer: Monida PacificSource	$783.75

ER CARDIOVERSION ELECTIVE EXTERNAL(DEFIB

Facility

$1,450.00

Service Code	HCPCS 92960
Hospital Charge Code	1092960
Hospital Revenue Code	450
Min. Negotiated Rate	$1,015.00
Max. Negotiated Rate	$1,450.00
Rate for Payer: Aetna Commercial	$1,377.50
Rate for Payer: Aetna Medicare	$1,305.00
Rate for Payer: BCBS MT CHIP	$1,305.00
Rate for Payer: BCBS MT Closed Plan Network	$1,377.50
Rate for Payer: BCBS MT HealthLink	$1,305.00
Rate for Payer: BCBS MT Medicare	$1,305.00
Rate for Payer: BCBS MT POS	$1,377.50
Rate for Payer: BCBS MT Traditional	$1,450.00
Rate for Payer: Cash Price	$1,305.00
Rate for Payer: Cigna Commercial	$1,377.50
Rate for Payer: Cigna Medicare	$1,305.00
Rate for Payer: Medicaid All Medicaid	$1,334.00
Rate for Payer: Medicare All Medicare	$1,015.00
Rate for Payer: Monida Allegiance	$1,377.50
Rate for Payer: Monida First Choice Health	$1,406.50
Rate for Payer: Monida Montana Health Co-op	$1,377.50
Rate for Payer: Monida PacificSource	$1,377.50

ER CARDIOVERSION ELECTIVE EXTERNAL(DEFIB

Facility

$1,450.00

Service Code	HCPCS 92960
Hospital Charge Code	1092960
Hospital Revenue Code	450
Min. Negotiated Rate	$1,015.00
Max. Negotiated Rate	$1,450.00
Rate for Payer: Aetna Commercial	$1,377.50
Rate for Payer: Aetna Medicare	$1,305.00
Rate for Payer: BCBS MT CHIP	$1,305.00
Rate for Payer: BCBS MT Closed Plan Network	$1,377.50
Rate for Payer: BCBS MT HealthLink	$1,305.00
Rate for Payer: BCBS MT Medicare	$1,305.00
Rate for Payer: BCBS MT POS	$1,377.50
Rate for Payer: BCBS MT Traditional	$1,450.00
Rate for Payer: Cash Price	$1,305.00
Rate for Payer: Cigna Commercial	$1,377.50
Rate for Payer: Cigna Medicare	$1,305.00
Rate for Payer: Medicaid All Medicaid	$1,334.00
Rate for Payer: Medicare All Medicare	$1,015.00
Rate for Payer: Monida Allegiance	$1,377.50
Rate for Payer: Monida First Choice Health	$1,406.50
Rate for Payer: Monida Montana Health Co-op	$1,377.50
Rate for Payer: Monida PacificSource	$1,377.50

ER CATH ASP NASOTRACHEAL

Facility

$187.00

Service Code	HCPCS 31720
Hospital Charge Code	1031720
Hospital Revenue Code	410
Min. Negotiated Rate	$130.90
Max. Negotiated Rate	$187.00
Rate for Payer: Aetna Commercial	$177.65
Rate for Payer: Aetna Medicare	$168.30
Rate for Payer: BCBS MT CHIP	$168.30
Rate for Payer: BCBS MT Closed Plan Network	$177.65
Rate for Payer: BCBS MT HealthLink	$168.30
Rate for Payer: BCBS MT Medicare	$168.30
Rate for Payer: BCBS MT POS	$177.65
Rate for Payer: BCBS MT Traditional	$187.00
Rate for Payer: Cash Price	$168.30
Rate for Payer: Cigna Commercial	$177.65
Rate for Payer: Cigna Medicare	$168.30
Rate for Payer: Medicaid All Medicaid	$172.04
Rate for Payer: Medicare All Medicare	$130.90
Rate for Payer: Monida Allegiance	$177.65
Rate for Payer: Monida First Choice Health	$181.39
Rate for Payer: Monida Montana Health Co-op	$177.65
Rate for Payer: Monida PacificSource	$177.65

ER CATH ASP NASOTRACHEAL

Facility

$187.00

Service Code	HCPCS 31720
Hospital Charge Code	1031720
Hospital Revenue Code	410
Min. Negotiated Rate	$130.90
Max. Negotiated Rate	$187.00
Rate for Payer: Aetna Commercial	$177.65
Rate for Payer: Aetna Medicare	$168.30
Rate for Payer: BCBS MT CHIP	$168.30
Rate for Payer: BCBS MT Closed Plan Network	$177.65
Rate for Payer: BCBS MT HealthLink	$168.30
Rate for Payer: BCBS MT Medicare	$168.30
Rate for Payer: BCBS MT POS	$177.65
Rate for Payer: BCBS MT Traditional	$187.00
Rate for Payer: Cash Price	$168.30
Rate for Payer: Cigna Commercial	$177.65
Rate for Payer: Cigna Medicare	$168.30
Rate for Payer: Medicaid All Medicaid	$172.04
Rate for Payer: Medicare All Medicare	$130.90
Rate for Payer: Monida Allegiance	$177.65
Rate for Payer: Monida First Choice Health	$181.39
Rate for Payer: Monida Montana Health Co-op	$177.65
Rate for Payer: Monida PacificSource	$177.65

Know your out-of-pocket cost for care.

All Charges