Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

ERPAK SULFA/TRIMETH TAB [800/160MG]4 TAB

Facility

$21.00

Service Code	HCPCS J3490
Hospital Charge Code	3000164
Hospital Revenue Code	250
Min. Negotiated Rate	$14.70
Max. Negotiated Rate	$21.00
Rate for Payer: Aetna Commercial	$19.95
Rate for Payer: Aetna Medicare	$18.90
Rate for Payer: BCBS MT CHIP	$18.90
Rate for Payer: BCBS MT Closed Plan Network	$19.95
Rate for Payer: BCBS MT HealthLink	$18.90
Rate for Payer: BCBS MT Medicare	$18.90
Rate for Payer: BCBS MT POS	$19.95
Rate for Payer: BCBS MT Traditional	$21.00
Rate for Payer: Cash Price	$18.90
Rate for Payer: Cigna Commercial	$19.95
Rate for Payer: Cigna Medicare	$18.90
Rate for Payer: Medicaid All Medicaid	$19.32
Rate for Payer: Medicare All Medicare	$14.70
Rate for Payer: Monida Allegiance	$19.95
Rate for Payer: Monida First Choice Health	$20.37
Rate for Payer: Monida Montana Health Co-op	$19.95
Rate for Payer: Monida PacificSource	$19.95

ERPAK TRAMADOL TAB [50 MG] 4 TAB PACK

Facility

$21.00

Service Code	HCPCS J3490
Hospital Charge Code	3000165
Hospital Revenue Code	250
Min. Negotiated Rate	$14.70
Max. Negotiated Rate	$21.00
Rate for Payer: Aetna Commercial	$19.95
Rate for Payer: Aetna Medicare	$18.90
Rate for Payer: BCBS MT CHIP	$18.90
Rate for Payer: BCBS MT Closed Plan Network	$19.95
Rate for Payer: BCBS MT HealthLink	$18.90
Rate for Payer: BCBS MT Medicare	$18.90
Rate for Payer: BCBS MT POS	$19.95
Rate for Payer: BCBS MT Traditional	$21.00
Rate for Payer: Cash Price	$18.90
Rate for Payer: Cigna Commercial	$19.95
Rate for Payer: Cigna Medicare	$18.90
Rate for Payer: Medicaid All Medicaid	$19.32
Rate for Payer: Medicare All Medicare	$14.70
Rate for Payer: Monida Allegiance	$19.95
Rate for Payer: Monida First Choice Health	$20.37
Rate for Payer: Monida Montana Health Co-op	$19.95
Rate for Payer: Monida PacificSource	$19.95

ERPAK TRAMADOL TAB [50 MG] 4 TAB PACK

Facility

$21.00

Service Code	HCPCS J3490
Hospital Charge Code	3000165
Hospital Revenue Code	250
Min. Negotiated Rate	$14.70
Max. Negotiated Rate	$21.00
Rate for Payer: Aetna Commercial	$19.95
Rate for Payer: Aetna Medicare	$18.90
Rate for Payer: BCBS MT CHIP	$18.90
Rate for Payer: BCBS MT Closed Plan Network	$19.95
Rate for Payer: BCBS MT HealthLink	$18.90
Rate for Payer: BCBS MT Medicare	$18.90
Rate for Payer: BCBS MT POS	$19.95
Rate for Payer: BCBS MT Traditional	$21.00
Rate for Payer: Cash Price	$18.90
Rate for Payer: Cigna Commercial	$19.95
Rate for Payer: Cigna Medicare	$18.90
Rate for Payer: Medicaid All Medicaid	$19.32
Rate for Payer: Medicare All Medicare	$14.70
Rate for Payer: Monida Allegiance	$19.95
Rate for Payer: Monida First Choice Health	$20.37
Rate for Payer: Monida Montana Health Co-op	$19.95
Rate for Payer: Monida PacificSource	$19.95

ER PLACE NEEDLE INFUSION INTRAOSSEOUS

Facility

$354.00

Service Code	HCPCS 36680
Hospital Charge Code	1033680
Hospital Revenue Code	450
Min. Negotiated Rate	$247.80
Max. Negotiated Rate	$354.00
Rate for Payer: Aetna Commercial	$336.30
Rate for Payer: Aetna Medicare	$318.60
Rate for Payer: BCBS MT CHIP	$318.60
Rate for Payer: BCBS MT Closed Plan Network	$336.30
Rate for Payer: BCBS MT HealthLink	$318.60
Rate for Payer: BCBS MT Medicare	$318.60
Rate for Payer: BCBS MT POS	$336.30
Rate for Payer: BCBS MT Traditional	$354.00
Rate for Payer: Cash Price	$318.60
Rate for Payer: Cigna Commercial	$336.30
Rate for Payer: Cigna Medicare	$318.60
Rate for Payer: Medicaid All Medicaid	$325.68
Rate for Payer: Medicare All Medicare	$247.80
Rate for Payer: Monida Allegiance	$336.30
Rate for Payer: Monida First Choice Health	$343.38
Rate for Payer: Monida Montana Health Co-op	$336.30
Rate for Payer: Monida PacificSource	$336.30

ER PLACE NEEDLE INFUSION INTRAOSSEOUS

Facility

$354.00

Service Code	HCPCS 36680
Hospital Charge Code	1033680
Hospital Revenue Code	450
Min. Negotiated Rate	$247.80
Max. Negotiated Rate	$354.00
Rate for Payer: Aetna Commercial	$336.30
Rate for Payer: Aetna Medicare	$318.60
Rate for Payer: BCBS MT CHIP	$318.60
Rate for Payer: BCBS MT Closed Plan Network	$336.30
Rate for Payer: BCBS MT HealthLink	$318.60
Rate for Payer: BCBS MT Medicare	$318.60
Rate for Payer: BCBS MT POS	$336.30
Rate for Payer: BCBS MT Traditional	$354.00
Rate for Payer: Cash Price	$318.60
Rate for Payer: Cigna Commercial	$336.30
Rate for Payer: Cigna Medicare	$318.60
Rate for Payer: Medicaid All Medicaid	$325.68
Rate for Payer: Medicare All Medicare	$247.80
Rate for Payer: Monida Allegiance	$336.30
Rate for Payer: Monida First Choice Health	$343.38
Rate for Payer: Monida Montana Health Co-op	$336.30
Rate for Payer: Monida PacificSource	$336.30

ER REDUCTION OF RECTAL PROLAPSE

Facility

$814.00

Service Code	HCPCS 45900
Hospital Charge Code	1045900
Hospital Revenue Code	450
Min. Negotiated Rate	$569.80
Max. Negotiated Rate	$814.00
Rate for Payer: Aetna Commercial	$773.30
Rate for Payer: Aetna Medicare	$732.60
Rate for Payer: BCBS MT CHIP	$732.60
Rate for Payer: BCBS MT Closed Plan Network	$773.30
Rate for Payer: BCBS MT HealthLink	$732.60
Rate for Payer: BCBS MT Medicare	$732.60
Rate for Payer: BCBS MT POS	$773.30
Rate for Payer: BCBS MT Traditional	$814.00
Rate for Payer: Cash Price	$732.60
Rate for Payer: Cigna Commercial	$773.30
Rate for Payer: Cigna Medicare	$732.60
Rate for Payer: Medicaid All Medicaid	$748.88
Rate for Payer: Medicare All Medicare	$569.80
Rate for Payer: Monida Allegiance	$773.30
Rate for Payer: Monida First Choice Health	$789.58
Rate for Payer: Monida Montana Health Co-op	$773.30
Rate for Payer: Monida PacificSource	$773.30

ER REDUCTION OF RECTAL PROLAPSE

Facility

$814.00

Service Code	HCPCS 45900
Hospital Charge Code	1045900
Hospital Revenue Code	450
Min. Negotiated Rate	$569.80
Max. Negotiated Rate	$814.00
Rate for Payer: Aetna Commercial	$773.30
Rate for Payer: Aetna Medicare	$732.60
Rate for Payer: BCBS MT CHIP	$732.60
Rate for Payer: BCBS MT Closed Plan Network	$773.30
Rate for Payer: BCBS MT HealthLink	$732.60
Rate for Payer: BCBS MT Medicare	$732.60
Rate for Payer: BCBS MT POS	$773.30
Rate for Payer: BCBS MT Traditional	$814.00
Rate for Payer: Cash Price	$732.60
Rate for Payer: Cigna Commercial	$773.30
Rate for Payer: Cigna Medicare	$732.60
Rate for Payer: Medicaid All Medicaid	$748.88
Rate for Payer: Medicare All Medicare	$569.80
Rate for Payer: Monida Allegiance	$773.30
Rate for Payer: Monida First Choice Health	$789.58
Rate for Payer: Monida Montana Health Co-op	$773.30
Rate for Payer: Monida PacificSource	$773.30

ER REMOVAL OF NAIL PLATE

Facility

$284.00

Service Code	HCPCS 11730
Hospital Charge Code	1011730
Hospital Revenue Code	450
Min. Negotiated Rate	$198.80
Max. Negotiated Rate	$284.00
Rate for Payer: Aetna Commercial	$269.80
Rate for Payer: Aetna Medicare	$255.60
Rate for Payer: BCBS MT CHIP	$255.60
Rate for Payer: BCBS MT Closed Plan Network	$269.80
Rate for Payer: BCBS MT HealthLink	$255.60
Rate for Payer: BCBS MT Medicare	$255.60
Rate for Payer: BCBS MT POS	$269.80
Rate for Payer: BCBS MT Traditional	$284.00
Rate for Payer: Cash Price	$255.60
Rate for Payer: Cigna Commercial	$269.80
Rate for Payer: Cigna Medicare	$255.60
Rate for Payer: Medicaid All Medicaid	$261.28
Rate for Payer: Medicare All Medicare	$198.80
Rate for Payer: Monida Allegiance	$269.80
Rate for Payer: Monida First Choice Health	$275.48
Rate for Payer: Monida Montana Health Co-op	$269.80
Rate for Payer: Monida PacificSource	$269.80

ER REMOVAL OF NAIL PLATE

Facility

$284.00

Service Code	HCPCS 11730
Hospital Charge Code	1011730
Hospital Revenue Code	450
Min. Negotiated Rate	$198.80
Max. Negotiated Rate	$284.00
Rate for Payer: Aetna Commercial	$269.80
Rate for Payer: Aetna Medicare	$255.60
Rate for Payer: BCBS MT CHIP	$255.60
Rate for Payer: BCBS MT Closed Plan Network	$269.80
Rate for Payer: BCBS MT HealthLink	$255.60
Rate for Payer: BCBS MT Medicare	$255.60
Rate for Payer: BCBS MT POS	$269.80
Rate for Payer: BCBS MT Traditional	$284.00
Rate for Payer: Cash Price	$255.60
Rate for Payer: Cigna Commercial	$269.80
Rate for Payer: Cigna Medicare	$255.60
Rate for Payer: Medicaid All Medicaid	$261.28
Rate for Payer: Medicare All Medicare	$198.80
Rate for Payer: Monida Allegiance	$269.80
Rate for Payer: Monida First Choice Health	$275.48
Rate for Payer: Monida Montana Health Co-op	$269.80
Rate for Payer: Monida PacificSource	$269.80

ER REMOVE FB DEEP OR COMLICATED

Facility

$3,577.00

Service Code	HCPCS 20525
Hospital Charge Code	1020525
Hospital Revenue Code	450
Min. Negotiated Rate	$2,503.90
Max. Negotiated Rate	$3,577.00
Rate for Payer: Aetna Commercial	$3,398.15
Rate for Payer: Aetna Medicare	$3,219.30
Rate for Payer: BCBS MT CHIP	$3,219.30
Rate for Payer: BCBS MT Closed Plan Network	$3,398.15
Rate for Payer: BCBS MT HealthLink	$3,219.30
Rate for Payer: BCBS MT Medicare	$3,219.30
Rate for Payer: BCBS MT POS	$3,398.15
Rate for Payer: BCBS MT Traditional	$3,577.00
Rate for Payer: Cash Price	$3,219.30
Rate for Payer: Cigna Commercial	$3,398.15
Rate for Payer: Cigna Medicare	$3,219.30
Rate for Payer: Medicaid All Medicaid	$3,290.84
Rate for Payer: Medicare All Medicare	$2,503.90
Rate for Payer: Monida Allegiance	$3,398.15
Rate for Payer: Monida First Choice Health	$3,469.69
Rate for Payer: Monida Montana Health Co-op	$3,398.15
Rate for Payer: Monida PacificSource	$3,398.15

ER REMOVE FB DEEP OR COMLICATED

Facility

$3,577.00

Service Code	HCPCS 20525
Hospital Charge Code	1020525
Hospital Revenue Code	450
Min. Negotiated Rate	$2,503.90
Max. Negotiated Rate	$3,577.00
Rate for Payer: Aetna Commercial	$3,398.15
Rate for Payer: Aetna Medicare	$3,219.30
Rate for Payer: BCBS MT CHIP	$3,219.30
Rate for Payer: BCBS MT Closed Plan Network	$3,398.15
Rate for Payer: BCBS MT HealthLink	$3,219.30
Rate for Payer: BCBS MT Medicare	$3,219.30
Rate for Payer: BCBS MT POS	$3,398.15
Rate for Payer: BCBS MT Traditional	$3,577.00
Rate for Payer: Cash Price	$3,219.30
Rate for Payer: Cigna Commercial	$3,398.15
Rate for Payer: Cigna Medicare	$3,219.30
Rate for Payer: Medicaid All Medicaid	$3,290.84
Rate for Payer: Medicare All Medicare	$2,503.90
Rate for Payer: Monida Allegiance	$3,398.15
Rate for Payer: Monida First Choice Health	$3,469.69
Rate for Payer: Monida Montana Health Co-op	$3,398.15
Rate for Payer: Monida PacificSource	$3,398.15

ER REMOVE FB MUSCLE/TENDON SHEATH SIMPLE

Facility

$1,742.00

Service Code	HCPCS 20520
Hospital Charge Code	1020520
Hospital Revenue Code	450
Min. Negotiated Rate	$1,219.40
Max. Negotiated Rate	$1,742.00
Rate for Payer: Aetna Commercial	$1,654.90
Rate for Payer: Aetna Medicare	$1,567.80
Rate for Payer: BCBS MT CHIP	$1,567.80
Rate for Payer: BCBS MT Closed Plan Network	$1,654.90
Rate for Payer: BCBS MT HealthLink	$1,567.80
Rate for Payer: BCBS MT Medicare	$1,567.80
Rate for Payer: BCBS MT POS	$1,654.90
Rate for Payer: BCBS MT Traditional	$1,742.00
Rate for Payer: Cash Price	$1,567.80
Rate for Payer: Cigna Commercial	$1,654.90
Rate for Payer: Cigna Medicare	$1,567.80
Rate for Payer: Medicaid All Medicaid	$1,602.64
Rate for Payer: Medicare All Medicare	$1,219.40
Rate for Payer: Monida Allegiance	$1,654.90
Rate for Payer: Monida First Choice Health	$1,689.74
Rate for Payer: Monida Montana Health Co-op	$1,654.90
Rate for Payer: Monida PacificSource	$1,654.90

ER REMOVE FB MUSCLE/TENDON SHEATH SIMPLE

Facility

$1,742.00

Service Code	HCPCS 20520
Hospital Charge Code	1020520
Hospital Revenue Code	450
Min. Negotiated Rate	$1,219.40
Max. Negotiated Rate	$1,742.00
Rate for Payer: Aetna Commercial	$1,654.90
Rate for Payer: Aetna Medicare	$1,567.80
Rate for Payer: BCBS MT CHIP	$1,567.80
Rate for Payer: BCBS MT Closed Plan Network	$1,654.90
Rate for Payer: BCBS MT HealthLink	$1,567.80
Rate for Payer: BCBS MT Medicare	$1,567.80
Rate for Payer: BCBS MT POS	$1,654.90
Rate for Payer: BCBS MT Traditional	$1,742.00
Rate for Payer: Cash Price	$1,567.80
Rate for Payer: Cigna Commercial	$1,654.90
Rate for Payer: Cigna Medicare	$1,567.80
Rate for Payer: Medicaid All Medicaid	$1,602.64
Rate for Payer: Medicare All Medicare	$1,219.40
Rate for Payer: Monida Allegiance	$1,654.90
Rate for Payer: Monida First Choice Health	$1,689.74
Rate for Payer: Monida Montana Health Co-op	$1,654.90
Rate for Payer: Monida PacificSource	$1,654.90

ER REMOVE FB UPPER ARM ELBOW AREA

Facility

$1,230.00

Service Code	HCPCS 24200
Hospital Charge Code	1024200
Hospital Revenue Code	450
Min. Negotiated Rate	$861.00
Max. Negotiated Rate	$1,230.00
Rate for Payer: Aetna Commercial	$1,168.50
Rate for Payer: Aetna Medicare	$1,107.00
Rate for Payer: BCBS MT CHIP	$1,107.00
Rate for Payer: BCBS MT Closed Plan Network	$1,168.50
Rate for Payer: BCBS MT HealthLink	$1,107.00
Rate for Payer: BCBS MT Medicare	$1,107.00
Rate for Payer: BCBS MT POS	$1,168.50
Rate for Payer: BCBS MT Traditional	$1,230.00
Rate for Payer: Cash Price	$1,107.00
Rate for Payer: Cigna Commercial	$1,168.50
Rate for Payer: Cigna Medicare	$1,107.00
Rate for Payer: Medicaid All Medicaid	$1,131.60
Rate for Payer: Medicare All Medicare	$861.00
Rate for Payer: Monida Allegiance	$1,168.50
Rate for Payer: Monida First Choice Health	$1,193.10
Rate for Payer: Monida Montana Health Co-op	$1,168.50
Rate for Payer: Monida PacificSource	$1,168.50

ER REMOVE FB UPPER ARM ELBOW AREA

Facility

$1,230.00

Service Code	HCPCS 24200
Hospital Charge Code	1024200
Hospital Revenue Code	450
Min. Negotiated Rate	$861.00
Max. Negotiated Rate	$1,230.00
Rate for Payer: Aetna Commercial	$1,168.50
Rate for Payer: Aetna Medicare	$1,107.00
Rate for Payer: BCBS MT CHIP	$1,107.00
Rate for Payer: BCBS MT Closed Plan Network	$1,168.50
Rate for Payer: BCBS MT HealthLink	$1,107.00
Rate for Payer: BCBS MT Medicare	$1,107.00
Rate for Payer: BCBS MT POS	$1,168.50
Rate for Payer: BCBS MT Traditional	$1,230.00
Rate for Payer: Cash Price	$1,107.00
Rate for Payer: Cigna Commercial	$1,168.50
Rate for Payer: Cigna Medicare	$1,107.00
Rate for Payer: Medicaid All Medicaid	$1,131.60
Rate for Payer: Medicare All Medicare	$861.00
Rate for Payer: Monida Allegiance	$1,168.50
Rate for Payer: Monida First Choice Health	$1,193.10
Rate for Payer: Monida Montana Health Co-op	$1,168.50
Rate for Payer: Monida PacificSource	$1,168.50

ER REMOVE FOREIGN BODY

Facility

$497.00

Service Code	HCPCS 10120
Hospital Charge Code	1010120
Hospital Revenue Code	450
Min. Negotiated Rate	$347.90
Max. Negotiated Rate	$497.00
Rate for Payer: Aetna Commercial	$472.15
Rate for Payer: Aetna Medicare	$447.30
Rate for Payer: BCBS MT CHIP	$447.30
Rate for Payer: BCBS MT Closed Plan Network	$472.15
Rate for Payer: BCBS MT HealthLink	$447.30
Rate for Payer: BCBS MT Medicare	$447.30
Rate for Payer: BCBS MT POS	$472.15
Rate for Payer: BCBS MT Traditional	$497.00
Rate for Payer: Cash Price	$447.30
Rate for Payer: Cigna Commercial	$472.15
Rate for Payer: Cigna Medicare	$447.30
Rate for Payer: Medicaid All Medicaid	$457.24
Rate for Payer: Medicare All Medicare	$347.90
Rate for Payer: Monida Allegiance	$472.15
Rate for Payer: Monida First Choice Health	$482.09
Rate for Payer: Monida Montana Health Co-op	$472.15
Rate for Payer: Monida PacificSource	$472.15

ER REMOVE FOREIGN BODY

Facility

$497.00

Service Code	HCPCS 10120
Hospital Charge Code	1010120
Hospital Revenue Code	450
Min. Negotiated Rate	$347.90
Max. Negotiated Rate	$497.00
Rate for Payer: Aetna Commercial	$472.15
Rate for Payer: Aetna Medicare	$447.30
Rate for Payer: BCBS MT CHIP	$447.30
Rate for Payer: BCBS MT Closed Plan Network	$472.15
Rate for Payer: BCBS MT HealthLink	$447.30
Rate for Payer: BCBS MT Medicare	$447.30
Rate for Payer: BCBS MT POS	$472.15
Rate for Payer: BCBS MT Traditional	$497.00
Rate for Payer: Cash Price	$447.30
Rate for Payer: Cigna Commercial	$472.15
Rate for Payer: Cigna Medicare	$447.30
Rate for Payer: Medicaid All Medicaid	$457.24
Rate for Payer: Medicare All Medicare	$347.90
Rate for Payer: Monida Allegiance	$472.15
Rate for Payer: Monida First Choice Health	$482.09
Rate for Payer: Monida Montana Health Co-op	$472.15
Rate for Payer: Monida PacificSource	$472.15

ER REMOVE FOREIGN BODY EYELID EXT CONJ

Facility

$222.00

Service Code	HCPCS 65205
Hospital Charge Code	1065205
Hospital Revenue Code	450
Min. Negotiated Rate	$155.40
Max. Negotiated Rate	$222.00
Rate for Payer: Aetna Commercial	$210.90
Rate for Payer: Aetna Medicare	$199.80
Rate for Payer: BCBS MT CHIP	$199.80
Rate for Payer: BCBS MT Closed Plan Network	$210.90
Rate for Payer: BCBS MT HealthLink	$199.80
Rate for Payer: BCBS MT Medicare	$199.80
Rate for Payer: BCBS MT POS	$210.90
Rate for Payer: BCBS MT Traditional	$222.00
Rate for Payer: Cash Price	$199.80
Rate for Payer: Cigna Commercial	$210.90
Rate for Payer: Cigna Medicare	$199.80
Rate for Payer: Medicaid All Medicaid	$204.24
Rate for Payer: Medicare All Medicare	$155.40
Rate for Payer: Monida Allegiance	$210.90
Rate for Payer: Monida First Choice Health	$215.34
Rate for Payer: Monida Montana Health Co-op	$210.90
Rate for Payer: Monida PacificSource	$210.90

ER REMOVE FOREIGN BODY EYELID EXT CONJ

Facility

$222.00

Service Code	HCPCS 65205
Hospital Charge Code	1065205
Hospital Revenue Code	450
Min. Negotiated Rate	$155.40
Max. Negotiated Rate	$222.00
Rate for Payer: Aetna Commercial	$210.90
Rate for Payer: Aetna Medicare	$199.80
Rate for Payer: BCBS MT CHIP	$199.80
Rate for Payer: BCBS MT Closed Plan Network	$210.90
Rate for Payer: BCBS MT HealthLink	$199.80
Rate for Payer: BCBS MT Medicare	$199.80
Rate for Payer: BCBS MT POS	$210.90
Rate for Payer: BCBS MT Traditional	$222.00
Rate for Payer: Cash Price	$199.80
Rate for Payer: Cigna Commercial	$210.90
Rate for Payer: Cigna Medicare	$199.80
Rate for Payer: Medicaid All Medicaid	$204.24
Rate for Payer: Medicare All Medicare	$155.40
Rate for Payer: Monida Allegiance	$210.90
Rate for Payer: Monida First Choice Health	$215.34
Rate for Payer: Monida Montana Health Co-op	$210.90
Rate for Payer: Monida PacificSource	$210.90

ER REMOVE NASAL FOREIGN BODY

Facility

$194.00

Service Code	HCPCS 30300
Hospital Charge Code	1030300
Hospital Revenue Code	450
Min. Negotiated Rate	$135.80
Max. Negotiated Rate	$194.00
Rate for Payer: Aetna Commercial	$184.30
Rate for Payer: Aetna Medicare	$174.60
Rate for Payer: BCBS MT CHIP	$174.60
Rate for Payer: BCBS MT Closed Plan Network	$184.30
Rate for Payer: BCBS MT HealthLink	$174.60
Rate for Payer: BCBS MT Medicare	$174.60
Rate for Payer: BCBS MT POS	$184.30
Rate for Payer: BCBS MT Traditional	$194.00
Rate for Payer: Cash Price	$174.60
Rate for Payer: Cigna Commercial	$184.30
Rate for Payer: Cigna Medicare	$174.60
Rate for Payer: Medicaid All Medicaid	$178.48
Rate for Payer: Medicare All Medicare	$135.80
Rate for Payer: Monida Allegiance	$184.30
Rate for Payer: Monida First Choice Health	$188.18
Rate for Payer: Monida Montana Health Co-op	$184.30
Rate for Payer: Monida PacificSource	$184.30

ER REMOVE NASAL FOREIGN BODY

Facility

$194.00

Service Code	HCPCS 30300
Hospital Charge Code	1030300
Hospital Revenue Code	450
Min. Negotiated Rate	$135.80
Max. Negotiated Rate	$194.00
Rate for Payer: Aetna Commercial	$184.30
Rate for Payer: Aetna Medicare	$174.60
Rate for Payer: BCBS MT CHIP	$174.60
Rate for Payer: BCBS MT Closed Plan Network	$184.30
Rate for Payer: BCBS MT HealthLink	$174.60
Rate for Payer: BCBS MT Medicare	$174.60
Rate for Payer: BCBS MT POS	$184.30
Rate for Payer: BCBS MT Traditional	$194.00
Rate for Payer: Cash Price	$174.60
Rate for Payer: Cigna Commercial	$184.30
Rate for Payer: Cigna Medicare	$174.60
Rate for Payer: Medicaid All Medicaid	$178.48
Rate for Payer: Medicare All Medicare	$135.80
Rate for Payer: Monida Allegiance	$184.30
Rate for Payer: Monida First Choice Health	$188.18
Rate for Payer: Monida Montana Health Co-op	$184.30
Rate for Payer: Monida PacificSource	$184.30

ER REMOV FOREIGN BODY EMBEDED EYLID EXT

Facility

$519.00

Service Code	HCPCS 67938
Hospital Charge Code	1067938
Hospital Revenue Code	450
Min. Negotiated Rate	$363.30
Max. Negotiated Rate	$519.00
Rate for Payer: Aetna Commercial	$493.05
Rate for Payer: Aetna Medicare	$467.10
Rate for Payer: BCBS MT CHIP	$467.10
Rate for Payer: BCBS MT Closed Plan Network	$493.05
Rate for Payer: BCBS MT HealthLink	$467.10
Rate for Payer: BCBS MT Medicare	$467.10
Rate for Payer: BCBS MT POS	$493.05
Rate for Payer: BCBS MT Traditional	$519.00
Rate for Payer: Cash Price	$467.10
Rate for Payer: Cigna Commercial	$493.05
Rate for Payer: Cigna Medicare	$467.10
Rate for Payer: Medicaid All Medicaid	$477.48
Rate for Payer: Medicare All Medicare	$363.30
Rate for Payer: Monida Allegiance	$493.05
Rate for Payer: Monida First Choice Health	$503.43
Rate for Payer: Monida Montana Health Co-op	$493.05
Rate for Payer: Monida PacificSource	$493.05

ER REMOV FOREIGN BODY EMBEDED EYLID EXT

Facility

$519.00

Service Code	HCPCS 67938
Hospital Charge Code	1067938
Hospital Revenue Code	450
Min. Negotiated Rate	$363.30
Max. Negotiated Rate	$519.00
Rate for Payer: Aetna Commercial	$493.05
Rate for Payer: Aetna Medicare	$467.10
Rate for Payer: BCBS MT CHIP	$467.10
Rate for Payer: BCBS MT Closed Plan Network	$493.05
Rate for Payer: BCBS MT HealthLink	$467.10
Rate for Payer: BCBS MT Medicare	$467.10
Rate for Payer: BCBS MT POS	$493.05
Rate for Payer: BCBS MT Traditional	$519.00
Rate for Payer: Cash Price	$467.10
Rate for Payer: Cigna Commercial	$493.05
Rate for Payer: Cigna Medicare	$467.10
Rate for Payer: Medicaid All Medicaid	$477.48
Rate for Payer: Medicare All Medicare	$363.30
Rate for Payer: Monida Allegiance	$493.05
Rate for Payer: Monida First Choice Health	$503.43
Rate for Payer: Monida Montana Health Co-op	$493.05
Rate for Payer: Monida PacificSource	$493.05

ER REPAIR COMPLEX 1.1-2.5 CM

Facility

$692.00

Service Code	HCPCS 13131
Hospital Charge Code	1013131
Hospital Revenue Code	450
Min. Negotiated Rate	$484.40
Max. Negotiated Rate	$692.00
Rate for Payer: Aetna Commercial	$657.40
Rate for Payer: Aetna Medicare	$622.80
Rate for Payer: BCBS MT CHIP	$622.80
Rate for Payer: BCBS MT Closed Plan Network	$657.40
Rate for Payer: BCBS MT HealthLink	$622.80
Rate for Payer: BCBS MT Medicare	$622.80
Rate for Payer: BCBS MT POS	$657.40
Rate for Payer: BCBS MT Traditional	$692.00
Rate for Payer: Cash Price	$622.80
Rate for Payer: Cigna Commercial	$657.40
Rate for Payer: Cigna Medicare	$622.80
Rate for Payer: Medicaid All Medicaid	$636.64
Rate for Payer: Medicare All Medicare	$484.40
Rate for Payer: Monida Allegiance	$657.40
Rate for Payer: Monida First Choice Health	$671.24
Rate for Payer: Monida Montana Health Co-op	$657.40
Rate for Payer: Monida PacificSource	$657.40

ER REPAIR COMPLEX 1.1-2.5 CM

Facility

$692.00

Service Code	HCPCS 13131
Hospital Charge Code	1013131
Hospital Revenue Code	450
Min. Negotiated Rate	$484.40
Max. Negotiated Rate	$692.00
Rate for Payer: Aetna Commercial	$657.40
Rate for Payer: Aetna Medicare	$622.80
Rate for Payer: BCBS MT CHIP	$622.80
Rate for Payer: BCBS MT Closed Plan Network	$657.40
Rate for Payer: BCBS MT HealthLink	$622.80
Rate for Payer: BCBS MT Medicare	$622.80
Rate for Payer: BCBS MT POS	$657.40
Rate for Payer: BCBS MT Traditional	$692.00
Rate for Payer: Cash Price	$622.80
Rate for Payer: Cigna Commercial	$657.40
Rate for Payer: Cigna Medicare	$622.80
Rate for Payer: Medicaid All Medicaid	$636.64
Rate for Payer: Medicare All Medicare	$484.40
Rate for Payer: Monida Allegiance	$657.40
Rate for Payer: Monida First Choice Health	$671.24
Rate for Payer: Monida Montana Health Co-op	$657.40
Rate for Payer: Monida PacificSource	$657.40

Know your out-of-pocket cost for care.

All Charges