Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

EPIFIX, 4X4.5 CM

Facility

$5,436.00

Service Code	HCPCS Q4186
Hospital Charge Code	8004201
Hospital Revenue Code	636
Min. Negotiated Rate	$3,805.20
Max. Negotiated Rate	$5,436.00
Rate for Payer: Aetna Commercial	$5,164.20
Rate for Payer: Aetna Medicare	$4,892.40
Rate for Payer: BCBS MT CHIP	$4,892.40
Rate for Payer: BCBS MT Closed Plan Network	$5,164.20
Rate for Payer: BCBS MT HealthLink	$4,892.40
Rate for Payer: BCBS MT Medicare	$4,892.40
Rate for Payer: BCBS MT POS	$5,164.20
Rate for Payer: BCBS MT Traditional	$5,436.00
Rate for Payer: Cash Price	$4,892.40
Rate for Payer: Cigna Commercial	$5,164.20
Rate for Payer: Cigna Medicare	$4,892.40
Rate for Payer: Medicaid All Medicaid	$5,001.12
Rate for Payer: Medicare All Medicare	$3,805.20
Rate for Payer: Monida Allegiance	$5,164.20
Rate for Payer: Monida First Choice Health	$5,272.92
Rate for Payer: Monida Montana Health Co-op	$5,164.20
Rate for Payer: Monida PacificSource	$5,164.20

EPINEPHRINE HCL INJ PEN [0.15 MG]

Facility

$571.00

Service Code	HCPCS J0169
Hospital Charge Code	3000145
Hospital Revenue Code	250
Min. Negotiated Rate	$399.70
Max. Negotiated Rate	$571.00
Rate for Payer: Aetna Commercial	$542.45
Rate for Payer: Aetna Medicare	$513.90
Rate for Payer: BCBS MT CHIP	$513.90
Rate for Payer: BCBS MT Closed Plan Network	$542.45
Rate for Payer: BCBS MT HealthLink	$513.90
Rate for Payer: BCBS MT Medicare	$513.90
Rate for Payer: BCBS MT POS	$542.45
Rate for Payer: BCBS MT Traditional	$571.00
Rate for Payer: Cash Price	$513.90
Rate for Payer: Cigna Commercial	$542.45
Rate for Payer: Cigna Medicare	$513.90
Rate for Payer: Medicaid All Medicaid	$525.32
Rate for Payer: Medicare All Medicare	$399.70
Rate for Payer: Monida Allegiance	$542.45
Rate for Payer: Monida First Choice Health	$553.87
Rate for Payer: Monida Montana Health Co-op	$542.45
Rate for Payer: Monida PacificSource	$542.45

EPINEPHRINE HCL INJ PEN [0.15 MG]

Facility

$571.00

Service Code	HCPCS J0169
Hospital Charge Code	3000145
Hospital Revenue Code	250
Min. Negotiated Rate	$399.70
Max. Negotiated Rate	$571.00
Rate for Payer: Aetna Commercial	$542.45
Rate for Payer: Aetna Medicare	$513.90
Rate for Payer: BCBS MT CHIP	$513.90
Rate for Payer: BCBS MT Closed Plan Network	$542.45
Rate for Payer: BCBS MT HealthLink	$513.90
Rate for Payer: BCBS MT Medicare	$513.90
Rate for Payer: BCBS MT POS	$542.45
Rate for Payer: BCBS MT Traditional	$571.00
Rate for Payer: Cash Price	$513.90
Rate for Payer: Cigna Commercial	$542.45
Rate for Payer: Cigna Medicare	$513.90
Rate for Payer: Medicaid All Medicaid	$525.32
Rate for Payer: Medicare All Medicare	$399.70
Rate for Payer: Monida Allegiance	$542.45
Rate for Payer: Monida First Choice Health	$553.87
Rate for Payer: Monida Montana Health Co-op	$542.45
Rate for Payer: Monida PacificSource	$542.45

EPINEPHRINE HCL INJ PEN [0.3 MG]

Facility

$571.00

Service Code	HCPCS J0169
Hospital Charge Code	3000146
Hospital Revenue Code	259
Min. Negotiated Rate	$399.70
Max. Negotiated Rate	$571.00
Rate for Payer: Aetna Commercial	$542.45
Rate for Payer: Aetna Medicare	$513.90
Rate for Payer: BCBS MT CHIP	$513.90
Rate for Payer: BCBS MT Closed Plan Network	$542.45
Rate for Payer: BCBS MT HealthLink	$513.90
Rate for Payer: BCBS MT Medicare	$513.90
Rate for Payer: BCBS MT POS	$542.45
Rate for Payer: BCBS MT Traditional	$571.00
Rate for Payer: Cash Price	$513.90
Rate for Payer: Cigna Commercial	$542.45
Rate for Payer: Cigna Medicare	$513.90
Rate for Payer: Medicaid All Medicaid	$525.32
Rate for Payer: Medicare All Medicare	$399.70
Rate for Payer: Monida Allegiance	$542.45
Rate for Payer: Monida First Choice Health	$553.87
Rate for Payer: Monida Montana Health Co-op	$542.45
Rate for Payer: Monida PacificSource	$542.45

EPINEPHRINE HCL INJ PEN [0.3 MG]

Facility

$571.00

Service Code	HCPCS J0169
Hospital Charge Code	3000146
Hospital Revenue Code	259
Min. Negotiated Rate	$399.70
Max. Negotiated Rate	$571.00
Rate for Payer: Aetna Commercial	$542.45
Rate for Payer: Aetna Medicare	$513.90
Rate for Payer: BCBS MT CHIP	$513.90
Rate for Payer: BCBS MT Closed Plan Network	$542.45
Rate for Payer: BCBS MT HealthLink	$513.90
Rate for Payer: BCBS MT Medicare	$513.90
Rate for Payer: BCBS MT POS	$542.45
Rate for Payer: BCBS MT Traditional	$571.00
Rate for Payer: Cash Price	$513.90
Rate for Payer: Cigna Commercial	$542.45
Rate for Payer: Cigna Medicare	$513.90
Rate for Payer: Medicaid All Medicaid	$525.32
Rate for Payer: Medicare All Medicare	$399.70
Rate for Payer: Monida Allegiance	$542.45
Rate for Payer: Monida First Choice Health	$553.87
Rate for Payer: Monida Montana Health Co-op	$542.45
Rate for Payer: Monida PacificSource	$542.45

EPINEPHRINE INJ [1 MG/ML] SDV

Facility

$56.00

Service Code	HCPCS J0169
Hospital Charge Code	3000147
Hospital Revenue Code	259
Min. Negotiated Rate	$39.20
Max. Negotiated Rate	$56.00
Rate for Payer: Aetna Commercial	$53.20
Rate for Payer: Aetna Medicare	$50.40
Rate for Payer: BCBS MT CHIP	$50.40
Rate for Payer: BCBS MT Closed Plan Network	$53.20
Rate for Payer: BCBS MT HealthLink	$50.40
Rate for Payer: BCBS MT Medicare	$50.40
Rate for Payer: BCBS MT POS	$53.20
Rate for Payer: BCBS MT Traditional	$56.00
Rate for Payer: Cash Price	$50.40
Rate for Payer: Cigna Commercial	$53.20
Rate for Payer: Cigna Medicare	$50.40
Rate for Payer: Medicaid All Medicaid	$51.52
Rate for Payer: Medicare All Medicare	$39.20
Rate for Payer: Monida Allegiance	$53.20
Rate for Payer: Monida First Choice Health	$54.32
Rate for Payer: Monida Montana Health Co-op	$53.20
Rate for Payer: Monida PacificSource	$53.20

EPINEPHRINE INJ [1 MG/ML] SDV

Facility

$56.00

Service Code	HCPCS J0169
Hospital Charge Code	3000147
Hospital Revenue Code	259
Min. Negotiated Rate	$39.20
Max. Negotiated Rate	$56.00
Rate for Payer: Aetna Commercial	$53.20
Rate for Payer: Aetna Medicare	$50.40
Rate for Payer: BCBS MT CHIP	$50.40
Rate for Payer: BCBS MT Closed Plan Network	$53.20
Rate for Payer: BCBS MT HealthLink	$50.40
Rate for Payer: BCBS MT Medicare	$50.40
Rate for Payer: BCBS MT POS	$53.20
Rate for Payer: BCBS MT Traditional	$56.00
Rate for Payer: Cash Price	$50.40
Rate for Payer: Cigna Commercial	$53.20
Rate for Payer: Cigna Medicare	$50.40
Rate for Payer: Medicaid All Medicaid	$51.52
Rate for Payer: Medicare All Medicare	$39.20
Rate for Payer: Monida Allegiance	$53.20
Rate for Payer: Monida First Choice Health	$54.32
Rate for Payer: Monida Montana Health Co-op	$53.20
Rate for Payer: Monida PacificSource	$53.20

EPINEPHRINE INJ SYR [1 MG/10 ML]

Facility

$26.00

Service Code	HCPCS J0169
Hospital Charge Code	3000148
Hospital Revenue Code	259
Min. Negotiated Rate	$18.20
Max. Negotiated Rate	$26.00
Rate for Payer: Aetna Commercial	$24.70
Rate for Payer: Aetna Medicare	$23.40
Rate for Payer: BCBS MT CHIP	$23.40
Rate for Payer: BCBS MT Closed Plan Network	$24.70
Rate for Payer: BCBS MT HealthLink	$23.40
Rate for Payer: BCBS MT Medicare	$23.40
Rate for Payer: BCBS MT POS	$24.70
Rate for Payer: BCBS MT Traditional	$26.00
Rate for Payer: Cash Price	$23.40
Rate for Payer: Cigna Commercial	$24.70
Rate for Payer: Cigna Medicare	$23.40
Rate for Payer: Medicaid All Medicaid	$23.92
Rate for Payer: Medicare All Medicare	$18.20
Rate for Payer: Monida Allegiance	$24.70
Rate for Payer: Monida First Choice Health	$25.22
Rate for Payer: Monida Montana Health Co-op	$24.70
Rate for Payer: Monida PacificSource	$24.70

EPINEPHRINE INJ SYR [1 MG/10 ML]

Facility

$26.00

Service Code	HCPCS J0169
Hospital Charge Code	3000148
Hospital Revenue Code	259
Min. Negotiated Rate	$18.20
Max. Negotiated Rate	$26.00
Rate for Payer: Aetna Commercial	$24.70
Rate for Payer: Aetna Medicare	$23.40
Rate for Payer: BCBS MT CHIP	$23.40
Rate for Payer: BCBS MT Closed Plan Network	$24.70
Rate for Payer: BCBS MT HealthLink	$23.40
Rate for Payer: BCBS MT Medicare	$23.40
Rate for Payer: BCBS MT POS	$24.70
Rate for Payer: BCBS MT Traditional	$26.00
Rate for Payer: Cash Price	$23.40
Rate for Payer: Cigna Commercial	$24.70
Rate for Payer: Cigna Medicare	$23.40
Rate for Payer: Medicaid All Medicaid	$23.92
Rate for Payer: Medicare All Medicare	$18.20
Rate for Payer: Monida Allegiance	$24.70
Rate for Payer: Monida First Choice Health	$25.22
Rate for Payer: Monida Montana Health Co-op	$24.70
Rate for Payer: Monida PacificSource	$24.70

EPISTAXIS COMPLEX- ER

Facility

$489.00

Service Code	HCPCS 30903
Hospital Charge Code	1030903
Hospital Revenue Code	450
Min. Negotiated Rate	$342.30
Max. Negotiated Rate	$489.00
Rate for Payer: Aetna Commercial	$464.55
Rate for Payer: Aetna Medicare	$440.10
Rate for Payer: BCBS MT CHIP	$440.10
Rate for Payer: BCBS MT Closed Plan Network	$464.55
Rate for Payer: BCBS MT HealthLink	$440.10
Rate for Payer: BCBS MT Medicare	$440.10
Rate for Payer: BCBS MT POS	$464.55
Rate for Payer: BCBS MT Traditional	$489.00
Rate for Payer: Cash Price	$440.10
Rate for Payer: Cigna Commercial	$464.55
Rate for Payer: Cigna Medicare	$440.10
Rate for Payer: Medicaid All Medicaid	$449.88
Rate for Payer: Medicare All Medicare	$342.30
Rate for Payer: Monida Allegiance	$464.55
Rate for Payer: Monida First Choice Health	$474.33
Rate for Payer: Monida Montana Health Co-op	$464.55
Rate for Payer: Monida PacificSource	$464.55

EPISTAXIS COMPLEX- ER

Facility

$489.00

Service Code	HCPCS 30903
Hospital Charge Code	1030903
Hospital Revenue Code	450
Min. Negotiated Rate	$342.30
Max. Negotiated Rate	$489.00
Rate for Payer: Aetna Commercial	$464.55
Rate for Payer: Aetna Medicare	$440.10
Rate for Payer: BCBS MT CHIP	$440.10
Rate for Payer: BCBS MT Closed Plan Network	$464.55
Rate for Payer: BCBS MT HealthLink	$440.10
Rate for Payer: BCBS MT Medicare	$440.10
Rate for Payer: BCBS MT POS	$464.55
Rate for Payer: BCBS MT Traditional	$489.00
Rate for Payer: Cash Price	$440.10
Rate for Payer: Cigna Commercial	$464.55
Rate for Payer: Cigna Medicare	$440.10
Rate for Payer: Medicaid All Medicaid	$449.88
Rate for Payer: Medicare All Medicare	$342.30
Rate for Payer: Monida Allegiance	$464.55
Rate for Payer: Monida First Choice Health	$474.33
Rate for Payer: Monida Montana Health Co-op	$464.55
Rate for Payer: Monida PacificSource	$464.55

EPISTAXIS INITIAL- ER

Facility

$357.00

Service Code	HCPCS 30905
Hospital Charge Code	1030905
Hospital Revenue Code	450
Min. Negotiated Rate	$249.90
Max. Negotiated Rate	$357.00
Rate for Payer: Aetna Commercial	$339.15
Rate for Payer: Aetna Medicare	$321.30
Rate for Payer: BCBS MT CHIP	$321.30
Rate for Payer: BCBS MT Closed Plan Network	$339.15
Rate for Payer: BCBS MT HealthLink	$321.30
Rate for Payer: BCBS MT Medicare	$321.30
Rate for Payer: BCBS MT POS	$339.15
Rate for Payer: BCBS MT Traditional	$357.00
Rate for Payer: Cash Price	$321.30
Rate for Payer: Cigna Commercial	$339.15
Rate for Payer: Cigna Medicare	$321.30
Rate for Payer: Medicaid All Medicaid	$328.44
Rate for Payer: Medicare All Medicare	$249.90
Rate for Payer: Monida Allegiance	$339.15
Rate for Payer: Monida First Choice Health	$346.29
Rate for Payer: Monida Montana Health Co-op	$339.15
Rate for Payer: Monida PacificSource	$339.15

EPISTAXIS INITIAL- ER

Facility

$357.00

Service Code	HCPCS 30905
Hospital Charge Code	1030905
Hospital Revenue Code	450
Min. Negotiated Rate	$249.90
Max. Negotiated Rate	$357.00
Rate for Payer: Aetna Commercial	$339.15
Rate for Payer: Aetna Medicare	$321.30
Rate for Payer: BCBS MT CHIP	$321.30
Rate for Payer: BCBS MT Closed Plan Network	$339.15
Rate for Payer: BCBS MT HealthLink	$321.30
Rate for Payer: BCBS MT Medicare	$321.30
Rate for Payer: BCBS MT POS	$339.15
Rate for Payer: BCBS MT Traditional	$357.00
Rate for Payer: Cash Price	$321.30
Rate for Payer: Cigna Commercial	$339.15
Rate for Payer: Cigna Medicare	$321.30
Rate for Payer: Medicaid All Medicaid	$328.44
Rate for Payer: Medicare All Medicare	$249.90
Rate for Payer: Monida Allegiance	$339.15
Rate for Payer: Monida First Choice Health	$346.29
Rate for Payer: Monida Montana Health Co-op	$339.15
Rate for Payer: Monida PacificSource	$339.15

EPISTAXIS SIMPLE- ER

Facility

$326.00

Service Code	HCPCS 30901
Hospital Charge Code	1030901
Hospital Revenue Code	450
Min. Negotiated Rate	$228.20
Max. Negotiated Rate	$326.00
Rate for Payer: Aetna Commercial	$309.70
Rate for Payer: Aetna Medicare	$293.40
Rate for Payer: BCBS MT CHIP	$293.40
Rate for Payer: BCBS MT Closed Plan Network	$309.70
Rate for Payer: BCBS MT HealthLink	$293.40
Rate for Payer: BCBS MT Medicare	$293.40
Rate for Payer: BCBS MT POS	$309.70
Rate for Payer: BCBS MT Traditional	$326.00
Rate for Payer: Cash Price	$293.40
Rate for Payer: Cigna Commercial	$309.70
Rate for Payer: Cigna Medicare	$293.40
Rate for Payer: Medicaid All Medicaid	$299.92
Rate for Payer: Medicare All Medicare	$228.20
Rate for Payer: Monida Allegiance	$309.70
Rate for Payer: Monida First Choice Health	$316.22
Rate for Payer: Monida Montana Health Co-op	$309.70
Rate for Payer: Monida PacificSource	$309.70

EPISTAXIS SIMPLE- ER

Facility

$326.00

Service Code	HCPCS 30901
Hospital Charge Code	1030901
Hospital Revenue Code	450
Min. Negotiated Rate	$228.20
Max. Negotiated Rate	$326.00
Rate for Payer: Aetna Commercial	$309.70
Rate for Payer: Aetna Medicare	$293.40
Rate for Payer: BCBS MT CHIP	$293.40
Rate for Payer: BCBS MT Closed Plan Network	$309.70
Rate for Payer: BCBS MT HealthLink	$293.40
Rate for Payer: BCBS MT Medicare	$293.40
Rate for Payer: BCBS MT POS	$309.70
Rate for Payer: BCBS MT Traditional	$326.00
Rate for Payer: Cash Price	$293.40
Rate for Payer: Cigna Commercial	$309.70
Rate for Payer: Cigna Medicare	$293.40
Rate for Payer: Medicaid All Medicaid	$299.92
Rate for Payer: Medicare All Medicare	$228.20
Rate for Payer: Monida Allegiance	$309.70
Rate for Payer: Monida First Choice Health	$316.22
Rate for Payer: Monida Montana Health Co-op	$309.70
Rate for Payer: Monida PacificSource	$309.70

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

Facility

$640.00

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

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

Facility

$640.00

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

ER APPLICATION OF FINGER SPLINT; DYNAMIC

Facility

$183.00

Service Code	HCPCS 29131
Hospital Charge Code	1029131
Hospital Revenue Code	450
Min. Negotiated Rate	$128.10
Max. Negotiated Rate	$183.00
Rate for Payer: Aetna Commercial	$173.85
Rate for Payer: Aetna Medicare	$164.70
Rate for Payer: BCBS MT CHIP	$164.70
Rate for Payer: BCBS MT Closed Plan Network	$173.85
Rate for Payer: BCBS MT HealthLink	$164.70
Rate for Payer: BCBS MT Medicare	$164.70
Rate for Payer: BCBS MT POS	$173.85
Rate for Payer: BCBS MT Traditional	$183.00
Rate for Payer: Cash Price	$164.70
Rate for Payer: Cigna Commercial	$173.85
Rate for Payer: Cigna Medicare	$164.70
Rate for Payer: Medicaid All Medicaid	$168.36
Rate for Payer: Medicare All Medicare	$128.10
Rate for Payer: Monida Allegiance	$173.85
Rate for Payer: Monida First Choice Health	$177.51
Rate for Payer: Monida Montana Health Co-op	$173.85
Rate for Payer: Monida PacificSource	$173.85

ER APPLICATION OF FINGER SPLINT; DYNAMIC

Facility

$183.00

Service Code	HCPCS 29131
Hospital Charge Code	1029131
Hospital Revenue Code	450
Min. Negotiated Rate	$128.10
Max. Negotiated Rate	$183.00
Rate for Payer: Aetna Commercial	$173.85
Rate for Payer: Aetna Medicare	$164.70
Rate for Payer: BCBS MT CHIP	$164.70
Rate for Payer: BCBS MT Closed Plan Network	$173.85
Rate for Payer: BCBS MT HealthLink	$164.70
Rate for Payer: BCBS MT Medicare	$164.70
Rate for Payer: BCBS MT POS	$173.85
Rate for Payer: BCBS MT Traditional	$183.00
Rate for Payer: Cash Price	$164.70
Rate for Payer: Cigna Commercial	$173.85
Rate for Payer: Cigna Medicare	$164.70
Rate for Payer: Medicaid All Medicaid	$168.36
Rate for Payer: Medicare All Medicare	$128.10
Rate for Payer: Monida Allegiance	$173.85
Rate for Payer: Monida First Choice Health	$177.51
Rate for Payer: Monida Montana Health Co-op	$173.85
Rate for Payer: Monida PacificSource	$173.85

ER APPLICATION OF FOREARM CAST

Facility

$284.00

Service Code	HCPCS 29075
Hospital Charge Code	1029075
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 APPLICATION OF FOREARM CAST

Facility

$284.00

Service Code	HCPCS 29075
Hospital Charge Code	1029075
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 APPLICATION SPLING TO ANKLE/AND OR FO

Facility

$179.00

Service Code	HCPCS 29540
Hospital Charge Code	1029540
Hospital Revenue Code	450
Min. Negotiated Rate	$125.30
Max. Negotiated Rate	$179.00
Rate for Payer: Aetna Commercial	$170.05
Rate for Payer: Aetna Medicare	$161.10
Rate for Payer: BCBS MT CHIP	$161.10
Rate for Payer: BCBS MT Closed Plan Network	$170.05
Rate for Payer: BCBS MT HealthLink	$161.10
Rate for Payer: BCBS MT Medicare	$161.10
Rate for Payer: BCBS MT POS	$170.05
Rate for Payer: BCBS MT Traditional	$179.00
Rate for Payer: Cash Price	$161.10
Rate for Payer: Cigna Commercial	$170.05
Rate for Payer: Cigna Medicare	$161.10
Rate for Payer: Medicaid All Medicaid	$164.68
Rate for Payer: Medicare All Medicare	$125.30
Rate for Payer: Monida Allegiance	$170.05
Rate for Payer: Monida First Choice Health	$173.63
Rate for Payer: Monida Montana Health Co-op	$170.05
Rate for Payer: Monida PacificSource	$170.05

ER APPLICATION SPLING TO ANKLE/AND OR FO

Facility

$179.00

Service Code	HCPCS 29540
Hospital Charge Code	1029540
Hospital Revenue Code	450
Min. Negotiated Rate	$125.30
Max. Negotiated Rate	$179.00
Rate for Payer: Aetna Commercial	$170.05
Rate for Payer: Aetna Medicare	$161.10
Rate for Payer: BCBS MT CHIP	$161.10
Rate for Payer: BCBS MT Closed Plan Network	$170.05
Rate for Payer: BCBS MT HealthLink	$161.10
Rate for Payer: BCBS MT Medicare	$161.10
Rate for Payer: BCBS MT POS	$170.05
Rate for Payer: BCBS MT Traditional	$179.00
Rate for Payer: Cash Price	$161.10
Rate for Payer: Cigna Commercial	$170.05
Rate for Payer: Cigna Medicare	$161.10
Rate for Payer: Medicaid All Medicaid	$164.68
Rate for Payer: Medicare All Medicare	$125.30
Rate for Payer: Monida Allegiance	$170.05
Rate for Payer: Monida First Choice Health	$173.63
Rate for Payer: Monida Montana Health Co-op	$170.05
Rate for Payer: Monida PacificSource	$170.05

ER APPLICATION SPLINT ARM SHORT

Facility

$330.00

Service Code	HCPCS 29125
Hospital Charge Code	1029125
Hospital Revenue Code	450
Min. Negotiated Rate	$231.00
Max. Negotiated Rate	$330.00
Rate for Payer: Aetna Commercial	$313.50
Rate for Payer: Aetna Medicare	$297.00
Rate for Payer: BCBS MT CHIP	$297.00
Rate for Payer: BCBS MT Closed Plan Network	$313.50
Rate for Payer: BCBS MT HealthLink	$297.00
Rate for Payer: BCBS MT Medicare	$297.00
Rate for Payer: BCBS MT POS	$313.50
Rate for Payer: BCBS MT Traditional	$330.00
Rate for Payer: Cash Price	$297.00
Rate for Payer: Cigna Commercial	$313.50
Rate for Payer: Cigna Medicare	$297.00
Rate for Payer: Medicaid All Medicaid	$303.60
Rate for Payer: Medicare All Medicare	$231.00
Rate for Payer: Monida Allegiance	$313.50
Rate for Payer: Monida First Choice Health	$320.10
Rate for Payer: Monida Montana Health Co-op	$313.50
Rate for Payer: Monida PacificSource	$313.50

ER APPLICATION SPLINT ARM SHORT

Facility

$330.00

Service Code	HCPCS 29125
Hospital Charge Code	1029125
Hospital Revenue Code	450
Min. Negotiated Rate	$231.00
Max. Negotiated Rate	$330.00
Rate for Payer: Aetna Commercial	$313.50
Rate for Payer: Aetna Medicare	$297.00
Rate for Payer: BCBS MT CHIP	$297.00
Rate for Payer: BCBS MT Closed Plan Network	$313.50
Rate for Payer: BCBS MT HealthLink	$297.00
Rate for Payer: BCBS MT Medicare	$297.00
Rate for Payer: BCBS MT POS	$313.50
Rate for Payer: BCBS MT Traditional	$330.00
Rate for Payer: Cash Price	$297.00
Rate for Payer: Cigna Commercial	$313.50
Rate for Payer: Cigna Medicare	$297.00
Rate for Payer: Medicaid All Medicaid	$303.60
Rate for Payer: Medicare All Medicare	$231.00
Rate for Payer: Monida Allegiance	$313.50
Rate for Payer: Monida First Choice Health	$320.10
Rate for Payer: Monida Montana Health Co-op	$313.50
Rate for Payer: Monida PacificSource	$313.50

Know your out-of-pocket cost for care.

All Charges