Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

ER CLOSED DISLOCATION ELBOW

Facility

$546.00

Service Code	HCPCS 24600
Hospital Charge Code	1024600
Hospital Revenue Code	450
Min. Negotiated Rate	$382.20
Max. Negotiated Rate	$546.00
Rate for Payer: Aetna Commercial	$518.70
Rate for Payer: Aetna Medicare	$491.40
Rate for Payer: BCBS MT CHIP	$491.40
Rate for Payer: BCBS MT Closed Plan Network	$518.70
Rate for Payer: BCBS MT HealthLink	$491.40
Rate for Payer: BCBS MT Medicare	$491.40
Rate for Payer: BCBS MT POS	$518.70
Rate for Payer: BCBS MT Traditional	$546.00
Rate for Payer: Cash Price	$491.40
Rate for Payer: Cigna Commercial	$518.70
Rate for Payer: Cigna Medicare	$491.40
Rate for Payer: Medicaid All Medicaid	$502.32
Rate for Payer: Medicare All Medicare	$382.20
Rate for Payer: Monida Allegiance	$518.70
Rate for Payer: Monida First Choice Health	$529.62
Rate for Payer: Monida Montana Health Co-op	$518.70
Rate for Payer: Monida PacificSource	$518.70

ER CLOSED DISLOCATION ELBOW

Facility

$546.00

Service Code	HCPCS 24600
Hospital Charge Code	1024600
Hospital Revenue Code	450
Min. Negotiated Rate	$382.20
Max. Negotiated Rate	$546.00
Rate for Payer: Aetna Commercial	$518.70
Rate for Payer: Aetna Medicare	$491.40
Rate for Payer: BCBS MT CHIP	$491.40
Rate for Payer: BCBS MT Closed Plan Network	$518.70
Rate for Payer: BCBS MT HealthLink	$491.40
Rate for Payer: BCBS MT Medicare	$491.40
Rate for Payer: BCBS MT POS	$518.70
Rate for Payer: BCBS MT Traditional	$546.00
Rate for Payer: Cash Price	$491.40
Rate for Payer: Cigna Commercial	$518.70
Rate for Payer: Cigna Medicare	$491.40
Rate for Payer: Medicaid All Medicaid	$502.32
Rate for Payer: Medicare All Medicare	$382.20
Rate for Payer: Monida Allegiance	$518.70
Rate for Payer: Monida First Choice Health	$529.62
Rate for Payer: Monida Montana Health Co-op	$518.70
Rate for Payer: Monida PacificSource	$518.70

ER CLOSED DISLOCATION OF THE TARSAL BONE

Facility

$404.00

Service Code	HCPCS 28540
Hospital Charge Code	1028540
Hospital Revenue Code	450
Min. Negotiated Rate	$282.80
Max. Negotiated Rate	$404.00
Rate for Payer: Aetna Commercial	$383.80
Rate for Payer: Aetna Medicare	$363.60
Rate for Payer: BCBS MT CHIP	$363.60
Rate for Payer: BCBS MT Closed Plan Network	$383.80
Rate for Payer: BCBS MT HealthLink	$363.60
Rate for Payer: BCBS MT Medicare	$363.60
Rate for Payer: BCBS MT POS	$383.80
Rate for Payer: BCBS MT Traditional	$404.00
Rate for Payer: Cash Price	$363.60
Rate for Payer: Cigna Commercial	$383.80
Rate for Payer: Cigna Medicare	$363.60
Rate for Payer: Medicaid All Medicaid	$371.68
Rate for Payer: Medicare All Medicare	$282.80
Rate for Payer: Monida Allegiance	$383.80
Rate for Payer: Monida First Choice Health	$391.88
Rate for Payer: Monida Montana Health Co-op	$383.80
Rate for Payer: Monida PacificSource	$383.80

ER CLOSED DISLOCATION OF THE TARSAL BONE

Facility

$404.00

Service Code	HCPCS 28540
Hospital Charge Code	1028540
Hospital Revenue Code	450
Min. Negotiated Rate	$282.80
Max. Negotiated Rate	$404.00
Rate for Payer: Aetna Commercial	$383.80
Rate for Payer: Aetna Medicare	$363.60
Rate for Payer: BCBS MT CHIP	$363.60
Rate for Payer: BCBS MT Closed Plan Network	$383.80
Rate for Payer: BCBS MT HealthLink	$363.60
Rate for Payer: BCBS MT Medicare	$363.60
Rate for Payer: BCBS MT POS	$383.80
Rate for Payer: BCBS MT Traditional	$404.00
Rate for Payer: Cash Price	$363.60
Rate for Payer: Cigna Commercial	$383.80
Rate for Payer: Cigna Medicare	$363.60
Rate for Payer: Medicaid All Medicaid	$371.68
Rate for Payer: Medicare All Medicare	$282.80
Rate for Payer: Monida Allegiance	$383.80
Rate for Payer: Monida First Choice Health	$391.88
Rate for Payer: Monida Montana Health Co-op	$383.80
Rate for Payer: Monida PacificSource	$383.80

ER CLOSED DISLOCATION OF THE THUMB

Facility

$469.00

Service Code	HCPCS 26641
Hospital Charge Code	1026641
Hospital Revenue Code	450
Min. Negotiated Rate	$328.30
Max. Negotiated Rate	$469.00
Rate for Payer: Aetna Commercial	$445.55
Rate for Payer: Aetna Medicare	$422.10
Rate for Payer: BCBS MT CHIP	$422.10
Rate for Payer: BCBS MT Closed Plan Network	$445.55
Rate for Payer: BCBS MT HealthLink	$422.10
Rate for Payer: BCBS MT Medicare	$422.10
Rate for Payer: BCBS MT POS	$445.55
Rate for Payer: BCBS MT Traditional	$469.00
Rate for Payer: Cash Price	$422.10
Rate for Payer: Cigna Commercial	$445.55
Rate for Payer: Cigna Medicare	$422.10
Rate for Payer: Medicaid All Medicaid	$431.48
Rate for Payer: Medicare All Medicare	$328.30
Rate for Payer: Monida Allegiance	$445.55
Rate for Payer: Monida First Choice Health	$454.93
Rate for Payer: Monida Montana Health Co-op	$445.55
Rate for Payer: Monida PacificSource	$445.55

ER CLOSED DISLOCATION OF THE THUMB

Facility

$469.00

Service Code	HCPCS 26641
Hospital Charge Code	1026641
Hospital Revenue Code	450
Min. Negotiated Rate	$328.30
Max. Negotiated Rate	$469.00
Rate for Payer: Aetna Commercial	$445.55
Rate for Payer: Aetna Medicare	$422.10
Rate for Payer: BCBS MT CHIP	$422.10
Rate for Payer: BCBS MT Closed Plan Network	$445.55
Rate for Payer: BCBS MT HealthLink	$422.10
Rate for Payer: BCBS MT Medicare	$422.10
Rate for Payer: BCBS MT POS	$445.55
Rate for Payer: BCBS MT Traditional	$469.00
Rate for Payer: Cash Price	$422.10
Rate for Payer: Cigna Commercial	$445.55
Rate for Payer: Cigna Medicare	$422.10
Rate for Payer: Medicaid All Medicaid	$431.48
Rate for Payer: Medicare All Medicare	$328.30
Rate for Payer: Monida Allegiance	$445.55
Rate for Payer: Monida First Choice Health	$454.93
Rate for Payer: Monida Montana Health Co-op	$445.55
Rate for Payer: Monida PacificSource	$445.55

ER CLOSED FX WRIST WITH MANIPULATION

Facility

$681.00

Service Code	HCPCS 25505
Hospital Charge Code	1025505
Hospital Revenue Code	450
Min. Negotiated Rate	$476.70
Max. Negotiated Rate	$681.00
Rate for Payer: Aetna Commercial	$646.95
Rate for Payer: Aetna Medicare	$612.90
Rate for Payer: BCBS MT CHIP	$612.90
Rate for Payer: BCBS MT Closed Plan Network	$646.95
Rate for Payer: BCBS MT HealthLink	$612.90
Rate for Payer: BCBS MT Medicare	$612.90
Rate for Payer: BCBS MT POS	$646.95
Rate for Payer: BCBS MT Traditional	$681.00
Rate for Payer: Cash Price	$612.90
Rate for Payer: Cigna Commercial	$646.95
Rate for Payer: Cigna Medicare	$612.90
Rate for Payer: Medicaid All Medicaid	$626.52
Rate for Payer: Medicare All Medicare	$476.70
Rate for Payer: Monida Allegiance	$646.95
Rate for Payer: Monida First Choice Health	$660.57
Rate for Payer: Monida Montana Health Co-op	$646.95
Rate for Payer: Monida PacificSource	$646.95

ER CLOSED FX WRIST WITH MANIPULATION

Facility

$681.00

Service Code	HCPCS 25505
Hospital Charge Code	1025505
Hospital Revenue Code	450
Min. Negotiated Rate	$476.70
Max. Negotiated Rate	$681.00
Rate for Payer: Aetna Commercial	$646.95
Rate for Payer: Aetna Medicare	$612.90
Rate for Payer: BCBS MT CHIP	$612.90
Rate for Payer: BCBS MT Closed Plan Network	$646.95
Rate for Payer: BCBS MT HealthLink	$612.90
Rate for Payer: BCBS MT Medicare	$612.90
Rate for Payer: BCBS MT POS	$646.95
Rate for Payer: BCBS MT Traditional	$681.00
Rate for Payer: Cash Price	$612.90
Rate for Payer: Cigna Commercial	$646.95
Rate for Payer: Cigna Medicare	$612.90
Rate for Payer: Medicaid All Medicaid	$626.52
Rate for Payer: Medicare All Medicare	$476.70
Rate for Payer: Monida Allegiance	$646.95
Rate for Payer: Monida First Choice Health	$660.57
Rate for Payer: Monida Montana Health Co-op	$646.95
Rate for Payer: Monida PacificSource	$646.95

ER CLOSED TX NOSE FX W/O STAB

Facility

$983.00

Service Code	HCPCS 21315
Hospital Charge Code	1021315
Hospital Revenue Code	450
Min. Negotiated Rate	$688.10
Max. Negotiated Rate	$983.00
Rate for Payer: Aetna Commercial	$933.85
Rate for Payer: Aetna Medicare	$884.70
Rate for Payer: BCBS MT CHIP	$884.70
Rate for Payer: BCBS MT Closed Plan Network	$933.85
Rate for Payer: BCBS MT HealthLink	$884.70
Rate for Payer: BCBS MT Medicare	$884.70
Rate for Payer: BCBS MT POS	$933.85
Rate for Payer: BCBS MT Traditional	$983.00
Rate for Payer: Cash Price	$884.70
Rate for Payer: Cigna Commercial	$933.85
Rate for Payer: Cigna Medicare	$884.70
Rate for Payer: Medicaid All Medicaid	$904.36
Rate for Payer: Medicare All Medicare	$688.10
Rate for Payer: Monida Allegiance	$933.85
Rate for Payer: Monida First Choice Health	$953.51
Rate for Payer: Monida Montana Health Co-op	$933.85
Rate for Payer: Monida PacificSource	$933.85

ER CLOSED TX NOSE FX W/O STAB

Facility

$983.00

Service Code	HCPCS 21315
Hospital Charge Code	1021315
Hospital Revenue Code	450
Min. Negotiated Rate	$688.10
Max. Negotiated Rate	$983.00
Rate for Payer: Aetna Commercial	$933.85
Rate for Payer: Aetna Medicare	$884.70
Rate for Payer: BCBS MT CHIP	$884.70
Rate for Payer: BCBS MT Closed Plan Network	$933.85
Rate for Payer: BCBS MT HealthLink	$884.70
Rate for Payer: BCBS MT Medicare	$884.70
Rate for Payer: BCBS MT POS	$933.85
Rate for Payer: BCBS MT Traditional	$983.00
Rate for Payer: Cash Price	$884.70
Rate for Payer: Cigna Commercial	$933.85
Rate for Payer: Cigna Medicare	$884.70
Rate for Payer: Medicaid All Medicaid	$904.36
Rate for Payer: Medicare All Medicare	$688.10
Rate for Payer: Monida Allegiance	$933.85
Rate for Payer: Monida First Choice Health	$953.51
Rate for Payer: Monida Montana Health Co-op	$933.85
Rate for Payer: Monida PacificSource	$933.85

ER CLSD TRT DISLC OF THE FINGER W/MANI

Facility

$481.00

Service Code	HCPCS 26700
Hospital Charge Code	1026700
Hospital Revenue Code	450
Min. Negotiated Rate	$336.70
Max. Negotiated Rate	$481.00
Rate for Payer: Aetna Commercial	$456.95
Rate for Payer: Aetna Medicare	$432.90
Rate for Payer: BCBS MT CHIP	$432.90
Rate for Payer: BCBS MT Closed Plan Network	$456.95
Rate for Payer: BCBS MT HealthLink	$432.90
Rate for Payer: BCBS MT Medicare	$432.90
Rate for Payer: BCBS MT POS	$456.95
Rate for Payer: BCBS MT Traditional	$481.00
Rate for Payer: Cash Price	$432.90
Rate for Payer: Cigna Commercial	$456.95
Rate for Payer: Cigna Medicare	$432.90
Rate for Payer: Medicaid All Medicaid	$442.52
Rate for Payer: Medicare All Medicare	$336.70
Rate for Payer: Monida Allegiance	$456.95
Rate for Payer: Monida First Choice Health	$466.57
Rate for Payer: Monida Montana Health Co-op	$456.95
Rate for Payer: Monida PacificSource	$456.95

ER CLSD TRT DISLC OF THE FINGER W/MANI

Facility

$481.00

Service Code	HCPCS 26700
Hospital Charge Code	1026700
Hospital Revenue Code	450
Min. Negotiated Rate	$336.70
Max. Negotiated Rate	$481.00
Rate for Payer: Aetna Commercial	$456.95
Rate for Payer: Aetna Medicare	$432.90
Rate for Payer: BCBS MT CHIP	$432.90
Rate for Payer: BCBS MT Closed Plan Network	$456.95
Rate for Payer: BCBS MT HealthLink	$432.90
Rate for Payer: BCBS MT Medicare	$432.90
Rate for Payer: BCBS MT POS	$456.95
Rate for Payer: BCBS MT Traditional	$481.00
Rate for Payer: Cash Price	$432.90
Rate for Payer: Cigna Commercial	$456.95
Rate for Payer: Cigna Medicare	$432.90
Rate for Payer: Medicaid All Medicaid	$442.52
Rate for Payer: Medicare All Medicare	$336.70
Rate for Payer: Monida Allegiance	$456.95
Rate for Payer: Monida First Choice Health	$466.57
Rate for Payer: Monida Montana Health Co-op	$456.95
Rate for Payer: Monida PacificSource	$456.95

ER CLTX OF FRAC OF THE FINGER EACH W/WO

Facility

$503.00

Service Code	HCPCS 26725
Hospital Charge Code	1026725
Hospital Revenue Code	450
Min. Negotiated Rate	$352.10
Max. Negotiated Rate	$503.00
Rate for Payer: Aetna Commercial	$477.85
Rate for Payer: Aetna Medicare	$452.70
Rate for Payer: BCBS MT CHIP	$452.70
Rate for Payer: BCBS MT Closed Plan Network	$477.85
Rate for Payer: BCBS MT HealthLink	$452.70
Rate for Payer: BCBS MT Medicare	$452.70
Rate for Payer: BCBS MT POS	$477.85
Rate for Payer: BCBS MT Traditional	$503.00
Rate for Payer: Cash Price	$452.70
Rate for Payer: Cigna Commercial	$477.85
Rate for Payer: Cigna Medicare	$452.70
Rate for Payer: Medicaid All Medicaid	$462.76
Rate for Payer: Medicare All Medicare	$352.10
Rate for Payer: Monida Allegiance	$477.85
Rate for Payer: Monida First Choice Health	$487.91
Rate for Payer: Monida Montana Health Co-op	$477.85
Rate for Payer: Monida PacificSource	$477.85

ER CLTX OF FRAC OF THE FINGER EACH W/WO

Facility

$503.00

Service Code	HCPCS 26725
Hospital Charge Code	1026725
Hospital Revenue Code	450
Min. Negotiated Rate	$352.10
Max. Negotiated Rate	$503.00
Rate for Payer: Aetna Commercial	$477.85
Rate for Payer: Aetna Medicare	$452.70
Rate for Payer: BCBS MT CHIP	$452.70
Rate for Payer: BCBS MT Closed Plan Network	$477.85
Rate for Payer: BCBS MT HealthLink	$452.70
Rate for Payer: BCBS MT Medicare	$452.70
Rate for Payer: BCBS MT POS	$477.85
Rate for Payer: BCBS MT Traditional	$503.00
Rate for Payer: Cash Price	$452.70
Rate for Payer: Cigna Commercial	$477.85
Rate for Payer: Cigna Medicare	$452.70
Rate for Payer: Medicaid All Medicaid	$462.76
Rate for Payer: Medicare All Medicare	$352.10
Rate for Payer: Monida Allegiance	$477.85
Rate for Payer: Monida First Choice Health	$487.91
Rate for Payer: Monida Montana Health Co-op	$477.85
Rate for Payer: Monida PacificSource	$477.85

ER DRAINAGE ABSC,CYST DENTOALVEOLAR41800

Facility

$516.00

Service Code	HCPCS 41800
Hospital Charge Code	1041800
Hospital Revenue Code	450
Min. Negotiated Rate	$361.20
Max. Negotiated Rate	$516.00
Rate for Payer: Aetna Commercial	$490.20
Rate for Payer: Aetna Medicare	$464.40
Rate for Payer: BCBS MT CHIP	$464.40
Rate for Payer: BCBS MT Closed Plan Network	$490.20
Rate for Payer: BCBS MT HealthLink	$464.40
Rate for Payer: BCBS MT Medicare	$464.40
Rate for Payer: BCBS MT POS	$490.20
Rate for Payer: BCBS MT Traditional	$516.00
Rate for Payer: Cash Price	$464.40
Rate for Payer: Cigna Commercial	$490.20
Rate for Payer: Cigna Medicare	$464.40
Rate for Payer: Medicaid All Medicaid	$474.72
Rate for Payer: Medicare All Medicare	$361.20
Rate for Payer: Monida Allegiance	$490.20
Rate for Payer: Monida First Choice Health	$500.52
Rate for Payer: Monida Montana Health Co-op	$490.20
Rate for Payer: Monida PacificSource	$490.20

ER DRAINAGE ABSC,CYST DENTOALVEOLAR41800

Facility

$516.00

Service Code	HCPCS 41800
Hospital Charge Code	1041800
Hospital Revenue Code	450
Min. Negotiated Rate	$361.20
Max. Negotiated Rate	$516.00
Rate for Payer: Aetna Commercial	$490.20
Rate for Payer: Aetna Medicare	$464.40
Rate for Payer: BCBS MT CHIP	$464.40
Rate for Payer: BCBS MT Closed Plan Network	$490.20
Rate for Payer: BCBS MT HealthLink	$464.40
Rate for Payer: BCBS MT Medicare	$464.40
Rate for Payer: BCBS MT POS	$490.20
Rate for Payer: BCBS MT Traditional	$516.00
Rate for Payer: Cash Price	$464.40
Rate for Payer: Cigna Commercial	$490.20
Rate for Payer: Cigna Medicare	$464.40
Rate for Payer: Medicaid All Medicaid	$474.72
Rate for Payer: Medicare All Medicare	$361.20
Rate for Payer: Monida Allegiance	$490.20
Rate for Payer: Monida First Choice Health	$500.52
Rate for Payer: Monida Montana Health Co-op	$490.20
Rate for Payer: Monida PacificSource	$490.20

ER DRAINAGE OF BARTHOLINS GLAND ABSCESS

Facility

$416.00

Service Code	HCPCS 56420
Hospital Charge Code	1056420
Hospital Revenue Code	450
Min. Negotiated Rate	$291.20
Max. Negotiated Rate	$416.00
Rate for Payer: Aetna Commercial	$395.20
Rate for Payer: Aetna Medicare	$374.40
Rate for Payer: BCBS MT CHIP	$374.40
Rate for Payer: BCBS MT Closed Plan Network	$395.20
Rate for Payer: BCBS MT HealthLink	$374.40
Rate for Payer: BCBS MT Medicare	$374.40
Rate for Payer: BCBS MT POS	$395.20
Rate for Payer: BCBS MT Traditional	$416.00
Rate for Payer: Cash Price	$374.40
Rate for Payer: Cigna Commercial	$395.20
Rate for Payer: Cigna Medicare	$374.40
Rate for Payer: Medicaid All Medicaid	$382.72
Rate for Payer: Medicare All Medicare	$291.20
Rate for Payer: Monida Allegiance	$395.20
Rate for Payer: Monida First Choice Health	$403.52
Rate for Payer: Monida Montana Health Co-op	$395.20
Rate for Payer: Monida PacificSource	$395.20

ER DRAINAGE OF BARTHOLINS GLAND ABSCESS

Facility

$416.00

Service Code	HCPCS 56420
Hospital Charge Code	1056420
Hospital Revenue Code	450
Min. Negotiated Rate	$291.20
Max. Negotiated Rate	$416.00
Rate for Payer: Aetna Commercial	$395.20
Rate for Payer: Aetna Medicare	$374.40
Rate for Payer: BCBS MT CHIP	$374.40
Rate for Payer: BCBS MT Closed Plan Network	$395.20
Rate for Payer: BCBS MT HealthLink	$374.40
Rate for Payer: BCBS MT Medicare	$374.40
Rate for Payer: BCBS MT POS	$395.20
Rate for Payer: BCBS MT Traditional	$416.00
Rate for Payer: Cash Price	$374.40
Rate for Payer: Cigna Commercial	$395.20
Rate for Payer: Cigna Medicare	$374.40
Rate for Payer: Medicaid All Medicaid	$382.72
Rate for Payer: Medicare All Medicare	$291.20
Rate for Payer: Monida Allegiance	$395.20
Rate for Payer: Monida First Choice Health	$403.52
Rate for Payer: Monida Montana Health Co-op	$395.20
Rate for Payer: Monida PacificSource	$395.20

ER DRAIN BLOOD FROM UNDER NAIL

Facility

$165.00

Service Code	HCPCS 11740
Hospital Charge Code	1011740
Hospital Revenue Code	450
Min. Negotiated Rate	$115.50
Max. Negotiated Rate	$165.00
Rate for Payer: Aetna Commercial	$156.75
Rate for Payer: Aetna Medicare	$148.50
Rate for Payer: BCBS MT CHIP	$148.50
Rate for Payer: BCBS MT Closed Plan Network	$156.75
Rate for Payer: BCBS MT HealthLink	$148.50
Rate for Payer: BCBS MT Medicare	$148.50
Rate for Payer: BCBS MT POS	$156.75
Rate for Payer: BCBS MT Traditional	$165.00
Rate for Payer: Cash Price	$148.50
Rate for Payer: Cigna Commercial	$156.75
Rate for Payer: Cigna Medicare	$148.50
Rate for Payer: Medicaid All Medicaid	$151.80
Rate for Payer: Medicare All Medicare	$115.50
Rate for Payer: Monida Allegiance	$156.75
Rate for Payer: Monida First Choice Health	$160.05
Rate for Payer: Monida Montana Health Co-op	$156.75
Rate for Payer: Monida PacificSource	$156.75

ER DRAIN BLOOD FROM UNDER NAIL

Facility

$165.00

Service Code	HCPCS 11740
Hospital Charge Code	1011740
Hospital Revenue Code	450
Min. Negotiated Rate	$115.50
Max. Negotiated Rate	$165.00
Rate for Payer: Aetna Commercial	$156.75
Rate for Payer: Aetna Medicare	$148.50
Rate for Payer: BCBS MT CHIP	$148.50
Rate for Payer: BCBS MT Closed Plan Network	$156.75
Rate for Payer: BCBS MT HealthLink	$148.50
Rate for Payer: BCBS MT Medicare	$148.50
Rate for Payer: BCBS MT POS	$156.75
Rate for Payer: BCBS MT Traditional	$165.00
Rate for Payer: Cash Price	$148.50
Rate for Payer: Cigna Commercial	$156.75
Rate for Payer: Cigna Medicare	$148.50
Rate for Payer: Medicaid All Medicaid	$151.80
Rate for Payer: Medicare All Medicare	$115.50
Rate for Payer: Monida Allegiance	$156.75
Rate for Payer: Monida First Choice Health	$160.05
Rate for Payer: Monida Montana Health Co-op	$156.75
Rate for Payer: Monida PacificSource	$156.75

ER DRESS/DEBRIDE BURN >10%TOTAL LARGE

Facility

$495.00

Service Code	HCPCS 16030
Hospital Charge Code	1016030
Hospital Revenue Code	450
Min. Negotiated Rate	$346.50
Max. Negotiated Rate	$495.00
Rate for Payer: Aetna Commercial	$470.25
Rate for Payer: Aetna Medicare	$445.50
Rate for Payer: BCBS MT CHIP	$445.50
Rate for Payer: BCBS MT Closed Plan Network	$470.25
Rate for Payer: BCBS MT HealthLink	$445.50
Rate for Payer: BCBS MT Medicare	$445.50
Rate for Payer: BCBS MT POS	$470.25
Rate for Payer: BCBS MT Traditional	$495.00
Rate for Payer: Cash Price	$445.50
Rate for Payer: Cigna Commercial	$470.25
Rate for Payer: Cigna Medicare	$445.50
Rate for Payer: Medicaid All Medicaid	$455.40
Rate for Payer: Medicare All Medicare	$346.50
Rate for Payer: Monida Allegiance	$470.25
Rate for Payer: Monida First Choice Health	$480.15
Rate for Payer: Monida Montana Health Co-op	$470.25
Rate for Payer: Monida PacificSource	$470.25

ER DRESS/DEBRIDE BURN >10%TOTAL LARGE

Facility

$495.00

Service Code	HCPCS 16030
Hospital Charge Code	1016030
Hospital Revenue Code	450
Min. Negotiated Rate	$346.50
Max. Negotiated Rate	$495.00
Rate for Payer: Aetna Commercial	$470.25
Rate for Payer: Aetna Medicare	$445.50
Rate for Payer: BCBS MT CHIP	$445.50
Rate for Payer: BCBS MT Closed Plan Network	$470.25
Rate for Payer: BCBS MT HealthLink	$445.50
Rate for Payer: BCBS MT Medicare	$445.50
Rate for Payer: BCBS MT POS	$470.25
Rate for Payer: BCBS MT Traditional	$495.00
Rate for Payer: Cash Price	$445.50
Rate for Payer: Cigna Commercial	$470.25
Rate for Payer: Cigna Medicare	$445.50
Rate for Payer: Medicaid All Medicaid	$455.40
Rate for Payer: Medicare All Medicare	$346.50
Rate for Payer: Monida Allegiance	$470.25
Rate for Payer: Monida First Choice Health	$480.15
Rate for Payer: Monida Montana Health Co-op	$470.25
Rate for Payer: Monida PacificSource	$470.25

ER DRESS/DEBRIDE PART-THICK BURNS >5%

Facility

$365.00

Service Code	HCPCS 16020
Hospital Charge Code	1016020
Hospital Revenue Code	450
Min. Negotiated Rate	$255.50
Max. Negotiated Rate	$365.00
Rate for Payer: Aetna Commercial	$346.75
Rate for Payer: Aetna Medicare	$328.50
Rate for Payer: BCBS MT CHIP	$328.50
Rate for Payer: BCBS MT Closed Plan Network	$346.75
Rate for Payer: BCBS MT HealthLink	$328.50
Rate for Payer: BCBS MT Medicare	$328.50
Rate for Payer: BCBS MT POS	$346.75
Rate for Payer: BCBS MT Traditional	$365.00
Rate for Payer: Cash Price	$328.50
Rate for Payer: Cigna Commercial	$346.75
Rate for Payer: Cigna Medicare	$328.50
Rate for Payer: Medicaid All Medicaid	$335.80
Rate for Payer: Medicare All Medicare	$255.50
Rate for Payer: Monida Allegiance	$346.75
Rate for Payer: Monida First Choice Health	$354.05
Rate for Payer: Monida Montana Health Co-op	$346.75
Rate for Payer: Monida PacificSource	$346.75

ER DRESS/DEBRIDE PART-THICK BURNS >5%

Facility

$365.00

Service Code	HCPCS 16020
Hospital Charge Code	1016020
Hospital Revenue Code	450
Min. Negotiated Rate	$255.50
Max. Negotiated Rate	$365.00
Rate for Payer: Aetna Commercial	$346.75
Rate for Payer: Aetna Medicare	$328.50
Rate for Payer: BCBS MT CHIP	$328.50
Rate for Payer: BCBS MT Closed Plan Network	$346.75
Rate for Payer: BCBS MT HealthLink	$328.50
Rate for Payer: BCBS MT Medicare	$328.50
Rate for Payer: BCBS MT POS	$346.75
Rate for Payer: BCBS MT Traditional	$365.00
Rate for Payer: Cash Price	$328.50
Rate for Payer: Cigna Commercial	$346.75
Rate for Payer: Cigna Medicare	$328.50
Rate for Payer: Medicaid All Medicaid	$335.80
Rate for Payer: Medicare All Medicare	$255.50
Rate for Payer: Monida Allegiance	$346.75
Rate for Payer: Monida First Choice Health	$354.05
Rate for Payer: Monida Montana Health Co-op	$346.75
Rate for Payer: Monida PacificSource	$346.75

ER GASTRIC INTUBATION

Facility

$353.00

Service Code	HCPCS 43753
Hospital Charge Code	1043753
Hospital Revenue Code	450
Min. Negotiated Rate	$247.10
Max. Negotiated Rate	$353.00
Rate for Payer: Aetna Commercial	$335.35
Rate for Payer: Aetna Medicare	$317.70
Rate for Payer: BCBS MT CHIP	$317.70
Rate for Payer: BCBS MT Closed Plan Network	$335.35
Rate for Payer: BCBS MT HealthLink	$317.70
Rate for Payer: BCBS MT Medicare	$317.70
Rate for Payer: BCBS MT POS	$335.35
Rate for Payer: BCBS MT Traditional	$353.00
Rate for Payer: Cash Price	$317.70
Rate for Payer: Cigna Commercial	$335.35
Rate for Payer: Cigna Medicare	$317.70
Rate for Payer: Medicaid All Medicaid	$324.76
Rate for Payer: Medicare All Medicare	$247.10
Rate for Payer: Monida Allegiance	$335.35
Rate for Payer: Monida First Choice Health	$342.41
Rate for Payer: Monida Montana Health Co-op	$335.35
Rate for Payer: Monida PacificSource	$335.35

Know your out-of-pocket cost for care.

All Charges