Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

ER REPAIR SIMPLE S/N/A/HF 20.1-30CM

Facility

$399.00

Service Code	HCPCS 12006
Hospital Charge Code	1012006
Hospital Revenue Code	450
Min. Negotiated Rate	$279.30
Max. Negotiated Rate	$399.00
Rate for Payer: Aetna Commercial	$379.05
Rate for Payer: Aetna Medicare	$359.10
Rate for Payer: BCBS MT CHIP	$359.10
Rate for Payer: BCBS MT Closed Plan Network	$379.05
Rate for Payer: BCBS MT HealthLink	$359.10
Rate for Payer: BCBS MT Medicare	$359.10
Rate for Payer: BCBS MT POS	$379.05
Rate for Payer: BCBS MT Traditional	$399.00
Rate for Payer: Cash Price	$359.10
Rate for Payer: Cigna Commercial	$379.05
Rate for Payer: Cigna Medicare	$359.10
Rate for Payer: Medicaid All Medicaid	$367.08
Rate for Payer: Medicare All Medicare	$279.30
Rate for Payer: Monida Allegiance	$379.05
Rate for Payer: Monida First Choice Health	$387.03
Rate for Payer: Monida Montana Health Co-op	$379.05
Rate for Payer: Monida PacificSource	$379.05

ER REPAIR SIMPLE S/N/A/HF 20.1-30CM

Facility

$399.00

Service Code	HCPCS 12006
Hospital Charge Code	1012006
Hospital Revenue Code	450
Min. Negotiated Rate	$279.30
Max. Negotiated Rate	$399.00
Rate for Payer: Aetna Commercial	$379.05
Rate for Payer: Aetna Medicare	$359.10
Rate for Payer: BCBS MT CHIP	$359.10
Rate for Payer: BCBS MT Closed Plan Network	$379.05
Rate for Payer: BCBS MT HealthLink	$359.10
Rate for Payer: BCBS MT Medicare	$359.10
Rate for Payer: BCBS MT POS	$379.05
Rate for Payer: BCBS MT Traditional	$399.00
Rate for Payer: Cash Price	$359.10
Rate for Payer: Cigna Commercial	$379.05
Rate for Payer: Cigna Medicare	$359.10
Rate for Payer: Medicaid All Medicaid	$367.08
Rate for Payer: Medicare All Medicare	$279.30
Rate for Payer: Monida Allegiance	$379.05
Rate for Payer: Monida First Choice Health	$387.03
Rate for Payer: Monida Montana Health Co-op	$379.05
Rate for Payer: Monida PacificSource	$379.05

ER REPAIR SIM,S/N/T/HF 12.6 TO 20CM

Facility

$377.00

Service Code	HCPCS 12005
Hospital Charge Code	1012005
Hospital Revenue Code	450
Min. Negotiated Rate	$263.90
Max. Negotiated Rate	$377.00
Rate for Payer: Aetna Commercial	$358.15
Rate for Payer: Aetna Medicare	$339.30
Rate for Payer: BCBS MT CHIP	$339.30
Rate for Payer: BCBS MT Closed Plan Network	$358.15
Rate for Payer: BCBS MT HealthLink	$339.30
Rate for Payer: BCBS MT Medicare	$339.30
Rate for Payer: BCBS MT POS	$358.15
Rate for Payer: BCBS MT Traditional	$377.00
Rate for Payer: Cash Price	$339.30
Rate for Payer: Cigna Commercial	$358.15
Rate for Payer: Cigna Medicare	$339.30
Rate for Payer: Medicaid All Medicaid	$346.84
Rate for Payer: Medicare All Medicare	$263.90
Rate for Payer: Monida Allegiance	$358.15
Rate for Payer: Monida First Choice Health	$365.69
Rate for Payer: Monida Montana Health Co-op	$358.15
Rate for Payer: Monida PacificSource	$358.15

ER REPAIR SIM,S/N/T/HF 12.6 TO 20CM

Facility

$377.00

Service Code	HCPCS 12005
Hospital Charge Code	1012005
Hospital Revenue Code	450
Min. Negotiated Rate	$263.90
Max. Negotiated Rate	$377.00
Rate for Payer: Aetna Commercial	$358.15
Rate for Payer: Aetna Medicare	$339.30
Rate for Payer: BCBS MT CHIP	$339.30
Rate for Payer: BCBS MT Closed Plan Network	$358.15
Rate for Payer: BCBS MT HealthLink	$339.30
Rate for Payer: BCBS MT Medicare	$339.30
Rate for Payer: BCBS MT POS	$358.15
Rate for Payer: BCBS MT Traditional	$377.00
Rate for Payer: Cash Price	$339.30
Rate for Payer: Cigna Commercial	$358.15
Rate for Payer: Cigna Medicare	$339.30
Rate for Payer: Medicaid All Medicaid	$346.84
Rate for Payer: Medicare All Medicare	$263.90
Rate for Payer: Monida Allegiance	$358.15
Rate for Payer: Monida First Choice Health	$365.69
Rate for Payer: Monida Montana Health Co-op	$358.15
Rate for Payer: Monida PacificSource	$358.15

ER ROOM/OPO EVALUATION FROM CLINIC

Facility

$89.00

Service Code	HCPCS 99211
Hospital Charge Code	1010111
Hospital Revenue Code	760
Min. Negotiated Rate	$62.30
Max. Negotiated Rate	$89.00
Rate for Payer: Aetna Commercial	$84.55
Rate for Payer: Aetna Medicare	$80.10
Rate for Payer: BCBS MT CHIP	$80.10
Rate for Payer: BCBS MT Closed Plan Network	$84.55
Rate for Payer: BCBS MT HealthLink	$80.10
Rate for Payer: BCBS MT Medicare	$80.10
Rate for Payer: BCBS MT POS	$84.55
Rate for Payer: BCBS MT Traditional	$89.00
Rate for Payer: Cash Price	$80.10
Rate for Payer: Cigna Commercial	$84.55
Rate for Payer: Cigna Medicare	$80.10
Rate for Payer: Medicaid All Medicaid	$81.88
Rate for Payer: Medicare All Medicare	$62.30
Rate for Payer: Monida Allegiance	$84.55
Rate for Payer: Monida First Choice Health	$86.33
Rate for Payer: Monida Montana Health Co-op	$84.55
Rate for Payer: Monida PacificSource	$84.55

ER ROOM/OPO EVALUATION FROM CLINIC

Facility

$89.00

Service Code	HCPCS 99211
Hospital Charge Code	1010111
Hospital Revenue Code	760
Min. Negotiated Rate	$62.30
Max. Negotiated Rate	$89.00
Rate for Payer: Aetna Commercial	$84.55
Rate for Payer: Aetna Medicare	$80.10
Rate for Payer: BCBS MT CHIP	$80.10
Rate for Payer: BCBS MT Closed Plan Network	$84.55
Rate for Payer: BCBS MT HealthLink	$80.10
Rate for Payer: BCBS MT Medicare	$80.10
Rate for Payer: BCBS MT POS	$84.55
Rate for Payer: BCBS MT Traditional	$89.00
Rate for Payer: Cash Price	$80.10
Rate for Payer: Cigna Commercial	$84.55
Rate for Payer: Cigna Medicare	$80.10
Rate for Payer: Medicaid All Medicaid	$81.88
Rate for Payer: Medicare All Medicare	$62.30
Rate for Payer: Monida Allegiance	$84.55
Rate for Payer: Monida First Choice Health	$86.33
Rate for Payer: Monida Montana Health Co-op	$84.55
Rate for Payer: Monida PacificSource	$84.55

ER ROOM/OP ROOM BRIEF 99281

Facility

$263.00

Service Code	HCPCS 99281 25
Hospital Charge Code	1010107
Hospital Revenue Code	450
Min. Negotiated Rate	$184.10
Max. Negotiated Rate	$263.00
Rate for Payer: Aetna Commercial	$249.85
Rate for Payer: Aetna Medicare	$236.70
Rate for Payer: BCBS MT CHIP	$236.70
Rate for Payer: BCBS MT Closed Plan Network	$249.85
Rate for Payer: BCBS MT HealthLink	$236.70
Rate for Payer: BCBS MT Medicare	$236.70
Rate for Payer: BCBS MT POS	$249.85
Rate for Payer: BCBS MT Traditional	$263.00
Rate for Payer: Cash Price	$236.70
Rate for Payer: Cigna Commercial	$249.85
Rate for Payer: Cigna Medicare	$236.70
Rate for Payer: Medicaid All Medicaid	$241.96
Rate for Payer: Medicare All Medicare	$184.10
Rate for Payer: Monida Allegiance	$249.85
Rate for Payer: Monida First Choice Health	$255.11
Rate for Payer: Monida Montana Health Co-op	$249.85
Rate for Payer: Monida PacificSource	$249.85

ER ROOM/OP ROOM BRIEF 99281

Facility

$263.00

Service Code	HCPCS 99281 25
Hospital Charge Code	1010107
Hospital Revenue Code	450
Min. Negotiated Rate	$184.10
Max. Negotiated Rate	$263.00
Rate for Payer: Aetna Commercial	$249.85
Rate for Payer: Aetna Medicare	$236.70
Rate for Payer: BCBS MT CHIP	$236.70
Rate for Payer: BCBS MT Closed Plan Network	$249.85
Rate for Payer: BCBS MT HealthLink	$236.70
Rate for Payer: BCBS MT Medicare	$236.70
Rate for Payer: BCBS MT POS	$249.85
Rate for Payer: BCBS MT Traditional	$263.00
Rate for Payer: Cash Price	$236.70
Rate for Payer: Cigna Commercial	$249.85
Rate for Payer: Cigna Medicare	$236.70
Rate for Payer: Medicaid All Medicaid	$241.96
Rate for Payer: Medicare All Medicare	$184.10
Rate for Payer: Monida Allegiance	$249.85
Rate for Payer: Monida First Choice Health	$255.11
Rate for Payer: Monida Montana Health Co-op	$249.85
Rate for Payer: Monida PacificSource	$249.85

ER ROOM/OP ROOM COMPREHENSIVE 99285

Facility

$1,720.00

Service Code	HCPCS 99285 25
Hospital Charge Code	1010106
Hospital Revenue Code	450
Min. Negotiated Rate	$1,204.00
Max. Negotiated Rate	$1,720.00
Rate for Payer: Aetna Commercial	$1,634.00
Rate for Payer: Aetna Medicare	$1,548.00
Rate for Payer: BCBS MT CHIP	$1,548.00
Rate for Payer: BCBS MT Closed Plan Network	$1,634.00
Rate for Payer: BCBS MT HealthLink	$1,548.00
Rate for Payer: BCBS MT Medicare	$1,548.00
Rate for Payer: BCBS MT POS	$1,634.00
Rate for Payer: BCBS MT Traditional	$1,720.00
Rate for Payer: Cash Price	$1,548.00
Rate for Payer: Cigna Commercial	$1,634.00
Rate for Payer: Cigna Medicare	$1,548.00
Rate for Payer: Medicaid All Medicaid	$1,582.40
Rate for Payer: Medicare All Medicare	$1,204.00
Rate for Payer: Monida Allegiance	$1,634.00
Rate for Payer: Monida First Choice Health	$1,668.40
Rate for Payer: Monida Montana Health Co-op	$1,634.00
Rate for Payer: Monida PacificSource	$1,634.00

ER ROOM/OP ROOM COMPREHENSIVE 99285

Facility

$1,720.00

Service Code	HCPCS 99285 25
Hospital Charge Code	1010106
Hospital Revenue Code	450
Min. Negotiated Rate	$1,204.00
Max. Negotiated Rate	$1,720.00
Rate for Payer: Aetna Commercial	$1,634.00
Rate for Payer: Aetna Medicare	$1,548.00
Rate for Payer: BCBS MT CHIP	$1,548.00
Rate for Payer: BCBS MT Closed Plan Network	$1,634.00
Rate for Payer: BCBS MT HealthLink	$1,548.00
Rate for Payer: BCBS MT Medicare	$1,548.00
Rate for Payer: BCBS MT POS	$1,634.00
Rate for Payer: BCBS MT Traditional	$1,720.00
Rate for Payer: Cash Price	$1,548.00
Rate for Payer: Cigna Commercial	$1,634.00
Rate for Payer: Cigna Medicare	$1,548.00
Rate for Payer: Medicaid All Medicaid	$1,582.40
Rate for Payer: Medicare All Medicare	$1,204.00
Rate for Payer: Monida Allegiance	$1,634.00
Rate for Payer: Monida First Choice Health	$1,668.40
Rate for Payer: Monida Montana Health Co-op	$1,634.00
Rate for Payer: Monida PacificSource	$1,634.00

ER ROOM/OP ROOM EXTENDED 99284

Facility

$1,152.00

Service Code	HCPCS 99284 25
Hospital Charge Code	1010105
Hospital Revenue Code	450
Min. Negotiated Rate	$806.40
Max. Negotiated Rate	$1,152.00
Rate for Payer: Aetna Commercial	$1,094.40
Rate for Payer: Aetna Medicare	$1,036.80
Rate for Payer: BCBS MT CHIP	$1,036.80
Rate for Payer: BCBS MT Closed Plan Network	$1,094.40
Rate for Payer: BCBS MT HealthLink	$1,036.80
Rate for Payer: BCBS MT Medicare	$1,036.80
Rate for Payer: BCBS MT POS	$1,094.40
Rate for Payer: BCBS MT Traditional	$1,152.00
Rate for Payer: Cash Price	$1,036.80
Rate for Payer: Cigna Commercial	$1,094.40
Rate for Payer: Cigna Medicare	$1,036.80
Rate for Payer: Medicaid All Medicaid	$1,059.84
Rate for Payer: Medicare All Medicare	$806.40
Rate for Payer: Monida Allegiance	$1,094.40
Rate for Payer: Monida First Choice Health	$1,117.44
Rate for Payer: Monida Montana Health Co-op	$1,094.40
Rate for Payer: Monida PacificSource	$1,094.40

ER ROOM/OP ROOM EXTENDED 99284

Facility

$1,152.00

Service Code	HCPCS 99284 25
Hospital Charge Code	1010105
Hospital Revenue Code	450
Min. Negotiated Rate	$806.40
Max. Negotiated Rate	$1,152.00
Rate for Payer: Aetna Commercial	$1,094.40
Rate for Payer: Aetna Medicare	$1,036.80
Rate for Payer: BCBS MT CHIP	$1,036.80
Rate for Payer: BCBS MT Closed Plan Network	$1,094.40
Rate for Payer: BCBS MT HealthLink	$1,036.80
Rate for Payer: BCBS MT Medicare	$1,036.80
Rate for Payer: BCBS MT POS	$1,094.40
Rate for Payer: BCBS MT Traditional	$1,152.00
Rate for Payer: Cash Price	$1,036.80
Rate for Payer: Cigna Commercial	$1,094.40
Rate for Payer: Cigna Medicare	$1,036.80
Rate for Payer: Medicaid All Medicaid	$1,059.84
Rate for Payer: Medicare All Medicare	$806.40
Rate for Payer: Monida Allegiance	$1,094.40
Rate for Payer: Monida First Choice Health	$1,117.44
Rate for Payer: Monida Montana Health Co-op	$1,094.40
Rate for Payer: Monida PacificSource	$1,094.40

ER ROOM/OP ROOM INTERMEDIATE 99283

Facility

$715.00

Service Code	HCPCS 99283 25
Hospital Charge Code	1010101
Hospital Revenue Code	450
Min. Negotiated Rate	$500.50
Max. Negotiated Rate	$715.00
Rate for Payer: Aetna Commercial	$679.25
Rate for Payer: Aetna Medicare	$643.50
Rate for Payer: BCBS MT CHIP	$643.50
Rate for Payer: BCBS MT Closed Plan Network	$679.25
Rate for Payer: BCBS MT HealthLink	$643.50
Rate for Payer: BCBS MT Medicare	$643.50
Rate for Payer: BCBS MT POS	$679.25
Rate for Payer: BCBS MT Traditional	$715.00
Rate for Payer: Cash Price	$643.50
Rate for Payer: Cigna Commercial	$679.25
Rate for Payer: Cigna Medicare	$643.50
Rate for Payer: Medicaid All Medicaid	$657.80
Rate for Payer: Medicare All Medicare	$500.50
Rate for Payer: Monida Allegiance	$679.25
Rate for Payer: Monida First Choice Health	$693.55
Rate for Payer: Monida Montana Health Co-op	$679.25
Rate for Payer: Monida PacificSource	$679.25

ER ROOM/OP ROOM INTERMEDIATE 99283

Facility

$715.00

Service Code	HCPCS 99283 25
Hospital Charge Code	1010101
Hospital Revenue Code	450
Min. Negotiated Rate	$500.50
Max. Negotiated Rate	$715.00
Rate for Payer: Aetna Commercial	$679.25
Rate for Payer: Aetna Medicare	$643.50
Rate for Payer: BCBS MT CHIP	$643.50
Rate for Payer: BCBS MT Closed Plan Network	$679.25
Rate for Payer: BCBS MT HealthLink	$643.50
Rate for Payer: BCBS MT Medicare	$643.50
Rate for Payer: BCBS MT POS	$679.25
Rate for Payer: BCBS MT Traditional	$715.00
Rate for Payer: Cash Price	$643.50
Rate for Payer: Cigna Commercial	$679.25
Rate for Payer: Cigna Medicare	$643.50
Rate for Payer: Medicaid All Medicaid	$657.80
Rate for Payer: Medicare All Medicare	$500.50
Rate for Payer: Monida Allegiance	$679.25
Rate for Payer: Monida First Choice Health	$693.55
Rate for Payer: Monida Montana Health Co-op	$679.25
Rate for Payer: Monida PacificSource	$679.25

ER ROOM/OP ROOM LIMITED 99282

Facility

$437.00

Service Code	HCPCS 99282 25
Hospital Charge Code	1010100
Hospital Revenue Code	450
Min. Negotiated Rate	$305.90
Max. Negotiated Rate	$437.00
Rate for Payer: Aetna Commercial	$415.15
Rate for Payer: Aetna Medicare	$393.30
Rate for Payer: BCBS MT CHIP	$393.30
Rate for Payer: BCBS MT Closed Plan Network	$415.15
Rate for Payer: BCBS MT HealthLink	$393.30
Rate for Payer: BCBS MT Medicare	$393.30
Rate for Payer: BCBS MT POS	$415.15
Rate for Payer: BCBS MT Traditional	$437.00
Rate for Payer: Cash Price	$393.30
Rate for Payer: Cigna Commercial	$415.15
Rate for Payer: Cigna Medicare	$393.30
Rate for Payer: Medicaid All Medicaid	$402.04
Rate for Payer: Medicare All Medicare	$305.90
Rate for Payer: Monida Allegiance	$415.15
Rate for Payer: Monida First Choice Health	$423.89
Rate for Payer: Monida Montana Health Co-op	$415.15
Rate for Payer: Monida PacificSource	$415.15

ER ROOM/OP ROOM LIMITED 99282

Facility

$437.00

Service Code	HCPCS 99282 25
Hospital Charge Code	1010100
Hospital Revenue Code	450
Min. Negotiated Rate	$305.90
Max. Negotiated Rate	$437.00
Rate for Payer: Aetna Commercial	$415.15
Rate for Payer: Aetna Medicare	$393.30
Rate for Payer: BCBS MT CHIP	$393.30
Rate for Payer: BCBS MT Closed Plan Network	$415.15
Rate for Payer: BCBS MT HealthLink	$393.30
Rate for Payer: BCBS MT Medicare	$393.30
Rate for Payer: BCBS MT POS	$415.15
Rate for Payer: BCBS MT Traditional	$437.00
Rate for Payer: Cash Price	$393.30
Rate for Payer: Cigna Commercial	$415.15
Rate for Payer: Cigna Medicare	$393.30
Rate for Payer: Medicaid All Medicaid	$402.04
Rate for Payer: Medicare All Medicare	$305.90
Rate for Payer: Monida Allegiance	$415.15
Rate for Payer: Monida First Choice Health	$423.89
Rate for Payer: Monida Montana Health Co-op	$415.15
Rate for Payer: Monida PacificSource	$415.15

ERTAPENEM 1GM VIAL SPECIAL ORDER

Facility

$333.00

Service Code	HCPCS J1335
Hospital Charge Code	3000166
Hospital Revenue Code	636
Min. Negotiated Rate	$233.10
Max. Negotiated Rate	$333.00
Rate for Payer: Aetna Commercial	$316.35
Rate for Payer: Aetna Medicare	$299.70
Rate for Payer: BCBS MT CHIP	$299.70
Rate for Payer: BCBS MT Closed Plan Network	$316.35
Rate for Payer: BCBS MT HealthLink	$299.70
Rate for Payer: BCBS MT Medicare	$299.70
Rate for Payer: BCBS MT POS	$316.35
Rate for Payer: BCBS MT Traditional	$333.00
Rate for Payer: Cash Price	$299.70
Rate for Payer: Cigna Commercial	$316.35
Rate for Payer: Cigna Medicare	$299.70
Rate for Payer: Medicaid All Medicaid	$306.36
Rate for Payer: Medicare All Medicare	$233.10
Rate for Payer: Monida Allegiance	$316.35
Rate for Payer: Monida First Choice Health	$323.01
Rate for Payer: Monida Montana Health Co-op	$316.35
Rate for Payer: Monida PacificSource	$316.35

ERTAPENEM 1GM VIAL SPECIAL ORDER

Facility

$333.00

Service Code	HCPCS J1335
Hospital Charge Code	3000166
Hospital Revenue Code	636
Min. Negotiated Rate	$233.10
Max. Negotiated Rate	$333.00
Rate for Payer: Aetna Commercial	$316.35
Rate for Payer: Aetna Medicare	$299.70
Rate for Payer: BCBS MT CHIP	$299.70
Rate for Payer: BCBS MT Closed Plan Network	$316.35
Rate for Payer: BCBS MT HealthLink	$299.70
Rate for Payer: BCBS MT Medicare	$299.70
Rate for Payer: BCBS MT POS	$316.35
Rate for Payer: BCBS MT Traditional	$333.00
Rate for Payer: Cash Price	$299.70
Rate for Payer: Cigna Commercial	$316.35
Rate for Payer: Cigna Medicare	$299.70
Rate for Payer: Medicaid All Medicaid	$306.36
Rate for Payer: Medicare All Medicare	$233.10
Rate for Payer: Monida Allegiance	$316.35
Rate for Payer: Monida First Choice Health	$323.01
Rate for Payer: Monida Montana Health Co-op	$316.35
Rate for Payer: Monida PacificSource	$316.35

ER TREAT ELBOW DISLOCATION

Facility

$415.00

Service Code	HCPCS 24640
Hospital Charge Code	1024640
Hospital Revenue Code	450
Min. Negotiated Rate	$290.50
Max. Negotiated Rate	$415.00
Rate for Payer: Aetna Commercial	$394.25
Rate for Payer: Aetna Medicare	$373.50
Rate for Payer: BCBS MT CHIP	$373.50
Rate for Payer: BCBS MT Closed Plan Network	$394.25
Rate for Payer: BCBS MT HealthLink	$373.50
Rate for Payer: BCBS MT Medicare	$373.50
Rate for Payer: BCBS MT POS	$394.25
Rate for Payer: BCBS MT Traditional	$415.00
Rate for Payer: Cash Price	$373.50
Rate for Payer: Cigna Commercial	$394.25
Rate for Payer: Cigna Medicare	$373.50
Rate for Payer: Medicaid All Medicaid	$381.80
Rate for Payer: Medicare All Medicare	$290.50
Rate for Payer: Monida Allegiance	$394.25
Rate for Payer: Monida First Choice Health	$402.55
Rate for Payer: Monida Montana Health Co-op	$394.25
Rate for Payer: Monida PacificSource	$394.25

ER TREAT ELBOW DISLOCATION

Facility

$415.00

Service Code	HCPCS 24640
Hospital Charge Code	1024640
Hospital Revenue Code	450
Min. Negotiated Rate	$290.50
Max. Negotiated Rate	$415.00
Rate for Payer: Aetna Commercial	$394.25
Rate for Payer: Aetna Medicare	$373.50
Rate for Payer: BCBS MT CHIP	$373.50
Rate for Payer: BCBS MT Closed Plan Network	$394.25
Rate for Payer: BCBS MT HealthLink	$373.50
Rate for Payer: BCBS MT Medicare	$373.50
Rate for Payer: BCBS MT POS	$394.25
Rate for Payer: BCBS MT Traditional	$415.00
Rate for Payer: Cash Price	$373.50
Rate for Payer: Cigna Commercial	$394.25
Rate for Payer: Cigna Medicare	$373.50
Rate for Payer: Medicaid All Medicaid	$381.80
Rate for Payer: Medicare All Medicare	$290.50
Rate for Payer: Monida Allegiance	$394.25
Rate for Payer: Monida First Choice Health	$402.55
Rate for Payer: Monida Montana Health Co-op	$394.25
Rate for Payer: Monida PacificSource	$394.25

ER TREAT SHOULDER DISLOCATION

Facility

$1,127.00

Service Code	HCPCS 23655
Hospital Charge Code	1023655
Hospital Revenue Code	450
Min. Negotiated Rate	$788.90
Max. Negotiated Rate	$1,127.00
Rate for Payer: Aetna Commercial	$1,070.65
Rate for Payer: Aetna Medicare	$1,014.30
Rate for Payer: BCBS MT CHIP	$1,014.30
Rate for Payer: BCBS MT Closed Plan Network	$1,070.65
Rate for Payer: BCBS MT HealthLink	$1,014.30
Rate for Payer: BCBS MT Medicare	$1,014.30
Rate for Payer: BCBS MT POS	$1,070.65
Rate for Payer: BCBS MT Traditional	$1,127.00
Rate for Payer: Cash Price	$1,014.30
Rate for Payer: Cigna Commercial	$1,070.65
Rate for Payer: Cigna Medicare	$1,014.30
Rate for Payer: Medicaid All Medicaid	$1,036.84
Rate for Payer: Medicare All Medicare	$788.90
Rate for Payer: Monida Allegiance	$1,070.65
Rate for Payer: Monida First Choice Health	$1,093.19
Rate for Payer: Monida Montana Health Co-op	$1,070.65
Rate for Payer: Monida PacificSource	$1,070.65

ER TREAT SHOULDER DISLOCATION

Facility

$1,127.00

Service Code	HCPCS 23655
Hospital Charge Code	1023655
Hospital Revenue Code	450
Min. Negotiated Rate	$788.90
Max. Negotiated Rate	$1,127.00
Rate for Payer: Aetna Commercial	$1,070.65
Rate for Payer: Aetna Medicare	$1,014.30
Rate for Payer: BCBS MT CHIP	$1,014.30
Rate for Payer: BCBS MT Closed Plan Network	$1,070.65
Rate for Payer: BCBS MT HealthLink	$1,014.30
Rate for Payer: BCBS MT Medicare	$1,014.30
Rate for Payer: BCBS MT POS	$1,070.65
Rate for Payer: BCBS MT Traditional	$1,127.00
Rate for Payer: Cash Price	$1,014.30
Rate for Payer: Cigna Commercial	$1,070.65
Rate for Payer: Cigna Medicare	$1,014.30
Rate for Payer: Medicaid All Medicaid	$1,036.84
Rate for Payer: Medicare All Medicare	$788.90
Rate for Payer: Monida Allegiance	$1,070.65
Rate for Payer: Monida First Choice Health	$1,093.19
Rate for Payer: Monida Montana Health Co-op	$1,070.65
Rate for Payer: Monida PacificSource	$1,070.65

ER TRIGEMINAL NERVE BLOCK 64400

Facility

$769.00

Service Code	HCPCS 64400
Hospital Charge Code	1064400
Hospital Revenue Code	450
Min. Negotiated Rate	$538.30
Max. Negotiated Rate	$769.00
Rate for Payer: Aetna Commercial	$730.55
Rate for Payer: Aetna Medicare	$692.10
Rate for Payer: BCBS MT CHIP	$692.10
Rate for Payer: BCBS MT Closed Plan Network	$730.55
Rate for Payer: BCBS MT HealthLink	$692.10
Rate for Payer: BCBS MT Medicare	$692.10
Rate for Payer: BCBS MT POS	$730.55
Rate for Payer: BCBS MT Traditional	$769.00
Rate for Payer: Cash Price	$692.10
Rate for Payer: Cigna Commercial	$730.55
Rate for Payer: Cigna Medicare	$692.10
Rate for Payer: Medicaid All Medicaid	$707.48
Rate for Payer: Medicare All Medicare	$538.30
Rate for Payer: Monida Allegiance	$730.55
Rate for Payer: Monida First Choice Health	$745.93
Rate for Payer: Monida Montana Health Co-op	$730.55
Rate for Payer: Monida PacificSource	$730.55

ER TRIGEMINAL NERVE BLOCK 64400

Facility

$769.00

Service Code	HCPCS 64400
Hospital Charge Code	1064400
Hospital Revenue Code	450
Min. Negotiated Rate	$538.30
Max. Negotiated Rate	$769.00
Rate for Payer: Aetna Commercial	$730.55
Rate for Payer: Aetna Medicare	$692.10
Rate for Payer: BCBS MT CHIP	$692.10
Rate for Payer: BCBS MT Closed Plan Network	$730.55
Rate for Payer: BCBS MT HealthLink	$692.10
Rate for Payer: BCBS MT Medicare	$692.10
Rate for Payer: BCBS MT POS	$730.55
Rate for Payer: BCBS MT Traditional	$769.00
Rate for Payer: Cash Price	$692.10
Rate for Payer: Cigna Commercial	$730.55
Rate for Payer: Cigna Medicare	$692.10
Rate for Payer: Medicaid All Medicaid	$707.48
Rate for Payer: Medicare All Medicare	$538.30
Rate for Payer: Monida Allegiance	$730.55
Rate for Payer: Monida First Choice Health	$745.93
Rate for Payer: Monida Montana Health Co-op	$730.55
Rate for Payer: Monida PacificSource	$730.55

ER TX BURN INITIAL 1ST DEGREE

Facility

$274.00

Service Code	HCPCS 16000
Hospital Charge Code	1016000
Hospital Revenue Code	450
Min. Negotiated Rate	$191.80
Max. Negotiated Rate	$274.00
Rate for Payer: Aetna Commercial	$260.30
Rate for Payer: Aetna Medicare	$246.60
Rate for Payer: BCBS MT CHIP	$246.60
Rate for Payer: BCBS MT Closed Plan Network	$260.30
Rate for Payer: BCBS MT HealthLink	$246.60
Rate for Payer: BCBS MT Medicare	$246.60
Rate for Payer: BCBS MT POS	$260.30
Rate for Payer: BCBS MT Traditional	$274.00
Rate for Payer: Cash Price	$246.60
Rate for Payer: Cigna Commercial	$260.30
Rate for Payer: Cigna Medicare	$246.60
Rate for Payer: Medicaid All Medicaid	$252.08
Rate for Payer: Medicare All Medicare	$191.80
Rate for Payer: Monida Allegiance	$260.30
Rate for Payer: Monida First Choice Health	$265.78
Rate for Payer: Monida Montana Health Co-op	$260.30
Rate for Payer: Monida PacificSource	$260.30

Know your out-of-pocket cost for care.

All Charges