Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

ER APPLICATION SPLINT FINGER STATIC

Facility

$249.00

Service Code	HCPCS 29130
Hospital Charge Code	1029130
Hospital Revenue Code	450
Min. Negotiated Rate	$174.30
Max. Negotiated Rate	$249.00
Rate for Payer: Aetna Commercial	$236.55
Rate for Payer: Aetna Medicare	$224.10
Rate for Payer: BCBS MT CHIP	$224.10
Rate for Payer: BCBS MT Closed Plan Network	$236.55
Rate for Payer: BCBS MT HealthLink	$224.10
Rate for Payer: BCBS MT Medicare	$224.10
Rate for Payer: BCBS MT POS	$236.55
Rate for Payer: BCBS MT Traditional	$249.00
Rate for Payer: Cash Price	$224.10
Rate for Payer: Cigna Commercial	$236.55
Rate for Payer: Cigna Medicare	$224.10
Rate for Payer: Medicaid All Medicaid	$229.08
Rate for Payer: Medicare All Medicare	$174.30
Rate for Payer: Monida Allegiance	$236.55
Rate for Payer: Monida First Choice Health	$241.53
Rate for Payer: Monida Montana Health Co-op	$236.55
Rate for Payer: Monida PacificSource	$236.55

ER APPLICATION SPLINT FINGER STATIC

Facility

$249.00

Service Code	HCPCS 29130
Hospital Charge Code	1029130
Hospital Revenue Code	450
Min. Negotiated Rate	$174.30
Max. Negotiated Rate	$249.00
Rate for Payer: Aetna Commercial	$236.55
Rate for Payer: Aetna Medicare	$224.10
Rate for Payer: BCBS MT CHIP	$224.10
Rate for Payer: BCBS MT Closed Plan Network	$236.55
Rate for Payer: BCBS MT HealthLink	$224.10
Rate for Payer: BCBS MT Medicare	$224.10
Rate for Payer: BCBS MT POS	$236.55
Rate for Payer: BCBS MT Traditional	$249.00
Rate for Payer: Cash Price	$224.10
Rate for Payer: Cigna Commercial	$236.55
Rate for Payer: Cigna Medicare	$224.10
Rate for Payer: Medicaid All Medicaid	$229.08
Rate for Payer: Medicare All Medicare	$174.30
Rate for Payer: Monida Allegiance	$236.55
Rate for Payer: Monida First Choice Health	$241.53
Rate for Payer: Monida Montana Health Co-op	$236.55
Rate for Payer: Monida PacificSource	$236.55

ER APPLICATION SPLINT HAND OR FINGER

Facility

$192.00

Service Code	HCPCS 29280
Hospital Charge Code	1029280
Hospital Revenue Code	450
Min. Negotiated Rate	$134.40
Max. Negotiated Rate	$192.00
Rate for Payer: Aetna Commercial	$182.40
Rate for Payer: Aetna Medicare	$172.80
Rate for Payer: BCBS MT CHIP	$172.80
Rate for Payer: BCBS MT Closed Plan Network	$182.40
Rate for Payer: BCBS MT HealthLink	$172.80
Rate for Payer: BCBS MT Medicare	$172.80
Rate for Payer: BCBS MT POS	$182.40
Rate for Payer: BCBS MT Traditional	$192.00
Rate for Payer: Cash Price	$172.80
Rate for Payer: Cigna Commercial	$182.40
Rate for Payer: Cigna Medicare	$172.80
Rate for Payer: Medicaid All Medicaid	$176.64
Rate for Payer: Medicare All Medicare	$134.40
Rate for Payer: Monida Allegiance	$182.40
Rate for Payer: Monida First Choice Health	$186.24
Rate for Payer: Monida Montana Health Co-op	$182.40
Rate for Payer: Monida PacificSource	$182.40

ER APPLICATION SPLINT HAND OR FINGER

Facility

$192.00

Service Code	HCPCS 29280
Hospital Charge Code	1029280
Hospital Revenue Code	450
Min. Negotiated Rate	$134.40
Max. Negotiated Rate	$192.00
Rate for Payer: Aetna Commercial	$182.40
Rate for Payer: Aetna Medicare	$172.80
Rate for Payer: BCBS MT CHIP	$172.80
Rate for Payer: BCBS MT Closed Plan Network	$182.40
Rate for Payer: BCBS MT HealthLink	$172.80
Rate for Payer: BCBS MT Medicare	$172.80
Rate for Payer: BCBS MT POS	$182.40
Rate for Payer: BCBS MT Traditional	$192.00
Rate for Payer: Cash Price	$172.80
Rate for Payer: Cigna Commercial	$182.40
Rate for Payer: Cigna Medicare	$172.80
Rate for Payer: Medicaid All Medicaid	$176.64
Rate for Payer: Medicare All Medicare	$134.40
Rate for Payer: Monida Allegiance	$182.40
Rate for Payer: Monida First Choice Health	$186.24
Rate for Payer: Monida Montana Health Co-op	$182.40
Rate for Payer: Monida PacificSource	$182.40

ER APPLICATION SPLINT LEG LONG

Facility

$348.00

Service Code	HCPCS 29505
Hospital Charge Code	1029505
Hospital Revenue Code	450
Min. Negotiated Rate	$243.60
Max. Negotiated Rate	$348.00
Rate for Payer: Aetna Commercial	$330.60
Rate for Payer: Aetna Medicare	$313.20
Rate for Payer: BCBS MT CHIP	$313.20
Rate for Payer: BCBS MT Closed Plan Network	$330.60
Rate for Payer: BCBS MT HealthLink	$313.20
Rate for Payer: BCBS MT Medicare	$313.20
Rate for Payer: BCBS MT POS	$330.60
Rate for Payer: BCBS MT Traditional	$348.00
Rate for Payer: Cash Price	$313.20
Rate for Payer: Cigna Commercial	$330.60
Rate for Payer: Cigna Medicare	$313.20
Rate for Payer: Medicaid All Medicaid	$320.16
Rate for Payer: Medicare All Medicare	$243.60
Rate for Payer: Monida Allegiance	$330.60
Rate for Payer: Monida First Choice Health	$337.56
Rate for Payer: Monida Montana Health Co-op	$330.60
Rate for Payer: Monida PacificSource	$330.60

ER APPLICATION SPLINT LEG LONG

Facility

$348.00

Service Code	HCPCS 29505
Hospital Charge Code	1029505
Hospital Revenue Code	450
Min. Negotiated Rate	$243.60
Max. Negotiated Rate	$348.00
Rate for Payer: Aetna Commercial	$330.60
Rate for Payer: Aetna Medicare	$313.20
Rate for Payer: BCBS MT CHIP	$313.20
Rate for Payer: BCBS MT Closed Plan Network	$330.60
Rate for Payer: BCBS MT HealthLink	$313.20
Rate for Payer: BCBS MT Medicare	$313.20
Rate for Payer: BCBS MT POS	$330.60
Rate for Payer: BCBS MT Traditional	$348.00
Rate for Payer: Cash Price	$313.20
Rate for Payer: Cigna Commercial	$330.60
Rate for Payer: Cigna Medicare	$313.20
Rate for Payer: Medicaid All Medicaid	$320.16
Rate for Payer: Medicare All Medicare	$243.60
Rate for Payer: Monida Allegiance	$330.60
Rate for Payer: Monida First Choice Health	$337.56
Rate for Payer: Monida Montana Health Co-op	$330.60
Rate for Payer: Monida PacificSource	$330.60

ER APPLICATION SPLINT LONG

Facility

$366.00

Service Code	HCPCS 29105
Hospital Charge Code	1029105
Hospital Revenue Code	450
Min. Negotiated Rate	$256.20
Max. Negotiated Rate	$366.00
Rate for Payer: Aetna Commercial	$347.70
Rate for Payer: Aetna Medicare	$329.40
Rate for Payer: BCBS MT CHIP	$329.40
Rate for Payer: BCBS MT Closed Plan Network	$347.70
Rate for Payer: BCBS MT HealthLink	$329.40
Rate for Payer: BCBS MT Medicare	$329.40
Rate for Payer: BCBS MT POS	$347.70
Rate for Payer: BCBS MT Traditional	$366.00
Rate for Payer: Cash Price	$329.40
Rate for Payer: Cigna Commercial	$347.70
Rate for Payer: Cigna Medicare	$329.40
Rate for Payer: Medicaid All Medicaid	$336.72
Rate for Payer: Medicare All Medicare	$256.20
Rate for Payer: Monida Allegiance	$347.70
Rate for Payer: Monida First Choice Health	$355.02
Rate for Payer: Monida Montana Health Co-op	$347.70
Rate for Payer: Monida PacificSource	$347.70

ER APPLICATION SPLINT LONG

Facility

$366.00

Service Code	HCPCS 29105
Hospital Charge Code	1029105
Hospital Revenue Code	450
Min. Negotiated Rate	$256.20
Max. Negotiated Rate	$366.00
Rate for Payer: Aetna Commercial	$347.70
Rate for Payer: Aetna Medicare	$329.40
Rate for Payer: BCBS MT CHIP	$329.40
Rate for Payer: BCBS MT Closed Plan Network	$347.70
Rate for Payer: BCBS MT HealthLink	$329.40
Rate for Payer: BCBS MT Medicare	$329.40
Rate for Payer: BCBS MT POS	$347.70
Rate for Payer: BCBS MT Traditional	$366.00
Rate for Payer: Cash Price	$329.40
Rate for Payer: Cigna Commercial	$347.70
Rate for Payer: Cigna Medicare	$329.40
Rate for Payer: Medicaid All Medicaid	$336.72
Rate for Payer: Medicare All Medicare	$256.20
Rate for Payer: Monida Allegiance	$347.70
Rate for Payer: Monida First Choice Health	$355.02
Rate for Payer: Monida Montana Health Co-op	$347.70
Rate for Payer: Monida PacificSource	$347.70

ER APPLICATION STRAPPING ELBOW OR WRIST

Facility

$202.00

Service Code	HCPCS 29260
Hospital Charge Code	1029260
Hospital Revenue Code	450
Min. Negotiated Rate	$141.40
Max. Negotiated Rate	$202.00
Rate for Payer: Aetna Commercial	$191.90
Rate for Payer: Aetna Medicare	$181.80
Rate for Payer: BCBS MT CHIP	$181.80
Rate for Payer: BCBS MT Closed Plan Network	$191.90
Rate for Payer: BCBS MT HealthLink	$181.80
Rate for Payer: BCBS MT Medicare	$181.80
Rate for Payer: BCBS MT POS	$191.90
Rate for Payer: BCBS MT Traditional	$202.00
Rate for Payer: Cash Price	$181.80
Rate for Payer: Cigna Commercial	$191.90
Rate for Payer: Cigna Medicare	$181.80
Rate for Payer: Medicaid All Medicaid	$185.84
Rate for Payer: Medicare All Medicare	$141.40
Rate for Payer: Monida Allegiance	$191.90
Rate for Payer: Monida First Choice Health	$195.94
Rate for Payer: Monida Montana Health Co-op	$191.90
Rate for Payer: Monida PacificSource	$191.90

ER APPLICATION STRAPPING ELBOW OR WRIST

Facility

$202.00

Service Code	HCPCS 29260
Hospital Charge Code	1029260
Hospital Revenue Code	450
Min. Negotiated Rate	$141.40
Max. Negotiated Rate	$202.00
Rate for Payer: Aetna Commercial	$191.90
Rate for Payer: Aetna Medicare	$181.80
Rate for Payer: BCBS MT CHIP	$181.80
Rate for Payer: BCBS MT Closed Plan Network	$191.90
Rate for Payer: BCBS MT HealthLink	$181.80
Rate for Payer: BCBS MT Medicare	$181.80
Rate for Payer: BCBS MT POS	$191.90
Rate for Payer: BCBS MT Traditional	$202.00
Rate for Payer: Cash Price	$181.80
Rate for Payer: Cigna Commercial	$191.90
Rate for Payer: Cigna Medicare	$181.80
Rate for Payer: Medicaid All Medicaid	$185.84
Rate for Payer: Medicare All Medicare	$141.40
Rate for Payer: Monida Allegiance	$191.90
Rate for Payer: Monida First Choice Health	$195.94
Rate for Payer: Monida Montana Health Co-op	$191.90
Rate for Payer: Monida PacificSource	$191.90

ER APPLICATION STRAPPING SHOULDER

Facility

$325.00

Service Code	HCPCS 29240
Hospital Charge Code	1029240
Hospital Revenue Code	450
Min. Negotiated Rate	$227.50
Max. Negotiated Rate	$325.00
Rate for Payer: Aetna Commercial	$308.75
Rate for Payer: Aetna Medicare	$292.50
Rate for Payer: BCBS MT CHIP	$292.50
Rate for Payer: BCBS MT Closed Plan Network	$308.75
Rate for Payer: BCBS MT HealthLink	$292.50
Rate for Payer: BCBS MT Medicare	$292.50
Rate for Payer: BCBS MT POS	$308.75
Rate for Payer: BCBS MT Traditional	$325.00
Rate for Payer: Cash Price	$292.50
Rate for Payer: Cigna Commercial	$308.75
Rate for Payer: Cigna Medicare	$292.50
Rate for Payer: Medicaid All Medicaid	$299.00
Rate for Payer: Medicare All Medicare	$227.50
Rate for Payer: Monida Allegiance	$308.75
Rate for Payer: Monida First Choice Health	$315.25
Rate for Payer: Monida Montana Health Co-op	$308.75
Rate for Payer: Monida PacificSource	$308.75

ER APPLICATION STRAPPING SHOULDER

Facility

$325.00

Service Code	HCPCS 29240
Hospital Charge Code	1029240
Hospital Revenue Code	450
Min. Negotiated Rate	$227.50
Max. Negotiated Rate	$325.00
Rate for Payer: Aetna Commercial	$308.75
Rate for Payer: Aetna Medicare	$292.50
Rate for Payer: BCBS MT CHIP	$292.50
Rate for Payer: BCBS MT Closed Plan Network	$308.75
Rate for Payer: BCBS MT HealthLink	$292.50
Rate for Payer: BCBS MT Medicare	$292.50
Rate for Payer: BCBS MT POS	$308.75
Rate for Payer: BCBS MT Traditional	$325.00
Rate for Payer: Cash Price	$292.50
Rate for Payer: Cigna Commercial	$308.75
Rate for Payer: Cigna Medicare	$292.50
Rate for Payer: Medicaid All Medicaid	$299.00
Rate for Payer: Medicare All Medicare	$227.50
Rate for Payer: Monida Allegiance	$308.75
Rate for Payer: Monida First Choice Health	$315.25
Rate for Payer: Monida Montana Health Co-op	$308.75
Rate for Payer: Monida PacificSource	$308.75

ER APPLY LONG LEG CAST

Facility

$348.00

Service Code	HCPCS 29345
Hospital Charge Code	1029345
Hospital Revenue Code	450
Min. Negotiated Rate	$243.60
Max. Negotiated Rate	$348.00
Rate for Payer: Aetna Commercial	$330.60
Rate for Payer: Aetna Medicare	$313.20
Rate for Payer: BCBS MT CHIP	$313.20
Rate for Payer: BCBS MT Closed Plan Network	$330.60
Rate for Payer: BCBS MT HealthLink	$313.20
Rate for Payer: BCBS MT Medicare	$313.20
Rate for Payer: BCBS MT POS	$330.60
Rate for Payer: BCBS MT Traditional	$348.00
Rate for Payer: Cash Price	$313.20
Rate for Payer: Cigna Commercial	$330.60
Rate for Payer: Cigna Medicare	$313.20
Rate for Payer: Medicaid All Medicaid	$320.16
Rate for Payer: Medicare All Medicare	$243.60
Rate for Payer: Monida Allegiance	$330.60
Rate for Payer: Monida First Choice Health	$337.56
Rate for Payer: Monida Montana Health Co-op	$330.60
Rate for Payer: Monida PacificSource	$330.60

ER APPLY LONG LEG CAST

Facility

$348.00

Service Code	HCPCS 29345
Hospital Charge Code	1029345
Hospital Revenue Code	450
Min. Negotiated Rate	$243.60
Max. Negotiated Rate	$348.00
Rate for Payer: Aetna Commercial	$330.60
Rate for Payer: Aetna Medicare	$313.20
Rate for Payer: BCBS MT CHIP	$313.20
Rate for Payer: BCBS MT Closed Plan Network	$330.60
Rate for Payer: BCBS MT HealthLink	$313.20
Rate for Payer: BCBS MT Medicare	$313.20
Rate for Payer: BCBS MT POS	$330.60
Rate for Payer: BCBS MT Traditional	$348.00
Rate for Payer: Cash Price	$313.20
Rate for Payer: Cigna Commercial	$330.60
Rate for Payer: Cigna Medicare	$313.20
Rate for Payer: Medicaid All Medicaid	$320.16
Rate for Payer: Medicare All Medicare	$243.60
Rate for Payer: Monida Allegiance	$330.60
Rate for Payer: Monida First Choice Health	$337.56
Rate for Payer: Monida Montana Health Co-op	$330.60
Rate for Payer: Monida PacificSource	$330.60

ER APPLY SHORT LEG CAST

Facility

$295.00

Service Code	HCPCS 29405
Hospital Charge Code	1029405
Hospital Revenue Code	450
Min. Negotiated Rate	$206.50
Max. Negotiated Rate	$295.00
Rate for Payer: Aetna Commercial	$280.25
Rate for Payer: Aetna Medicare	$265.50
Rate for Payer: BCBS MT CHIP	$265.50
Rate for Payer: BCBS MT Closed Plan Network	$280.25
Rate for Payer: BCBS MT HealthLink	$265.50
Rate for Payer: BCBS MT Medicare	$265.50
Rate for Payer: BCBS MT POS	$280.25
Rate for Payer: BCBS MT Traditional	$295.00
Rate for Payer: Cash Price	$265.50
Rate for Payer: Cigna Commercial	$280.25
Rate for Payer: Cigna Medicare	$265.50
Rate for Payer: Medicaid All Medicaid	$271.40
Rate for Payer: Medicare All Medicare	$206.50
Rate for Payer: Monida Allegiance	$280.25
Rate for Payer: Monida First Choice Health	$286.15
Rate for Payer: Monida Montana Health Co-op	$280.25
Rate for Payer: Monida PacificSource	$280.25

ER APPLY SHORT LEG CAST

Facility

$295.00

Service Code	HCPCS 29405
Hospital Charge Code	1029405
Hospital Revenue Code	450
Min. Negotiated Rate	$206.50
Max. Negotiated Rate	$295.00
Rate for Payer: Aetna Commercial	$280.25
Rate for Payer: Aetna Medicare	$265.50
Rate for Payer: BCBS MT CHIP	$265.50
Rate for Payer: BCBS MT Closed Plan Network	$280.25
Rate for Payer: BCBS MT HealthLink	$265.50
Rate for Payer: BCBS MT Medicare	$265.50
Rate for Payer: BCBS MT POS	$280.25
Rate for Payer: BCBS MT Traditional	$295.00
Rate for Payer: Cash Price	$265.50
Rate for Payer: Cigna Commercial	$280.25
Rate for Payer: Cigna Medicare	$265.50
Rate for Payer: Medicaid All Medicaid	$271.40
Rate for Payer: Medicare All Medicare	$206.50
Rate for Payer: Monida Allegiance	$280.25
Rate for Payer: Monida First Choice Health	$286.15
Rate for Payer: Monida Montana Health Co-op	$280.25
Rate for Payer: Monida PacificSource	$280.25

ER CARDIOPULMONARY RESUSCITATION

Facility

$875.00

Service Code	HCPCS 92950
Hospital Charge Code	1092950
Hospital Revenue Code	450
Min. Negotiated Rate	$612.50
Max. Negotiated Rate	$875.00
Rate for Payer: Aetna Commercial	$831.25
Rate for Payer: Aetna Medicare	$787.50
Rate for Payer: BCBS MT CHIP	$787.50
Rate for Payer: BCBS MT Closed Plan Network	$831.25
Rate for Payer: BCBS MT HealthLink	$787.50
Rate for Payer: BCBS MT Medicare	$787.50
Rate for Payer: BCBS MT POS	$831.25
Rate for Payer: BCBS MT Traditional	$875.00
Rate for Payer: Cash Price	$787.50
Rate for Payer: Cigna Commercial	$831.25
Rate for Payer: Cigna Medicare	$787.50
Rate for Payer: Medicaid All Medicaid	$805.00
Rate for Payer: Medicare All Medicare	$612.50
Rate for Payer: Monida Allegiance	$831.25
Rate for Payer: Monida First Choice Health	$848.75
Rate for Payer: Monida Montana Health Co-op	$831.25
Rate for Payer: Monida PacificSource	$831.25

ER CARDIOPULMONARY RESUSCITATION

Facility

$875.00

Service Code	HCPCS 92950
Hospital Charge Code	1092950
Hospital Revenue Code	450
Min. Negotiated Rate	$612.50
Max. Negotiated Rate	$875.00
Rate for Payer: Aetna Commercial	$831.25
Rate for Payer: Aetna Medicare	$787.50
Rate for Payer: BCBS MT CHIP	$787.50
Rate for Payer: BCBS MT Closed Plan Network	$831.25
Rate for Payer: BCBS MT HealthLink	$787.50
Rate for Payer: BCBS MT Medicare	$787.50
Rate for Payer: BCBS MT POS	$831.25
Rate for Payer: BCBS MT Traditional	$875.00
Rate for Payer: Cash Price	$787.50
Rate for Payer: Cigna Commercial	$831.25
Rate for Payer: Cigna Medicare	$787.50
Rate for Payer: Medicaid All Medicaid	$805.00
Rate for Payer: Medicare All Medicare	$612.50
Rate for Payer: Monida Allegiance	$831.25
Rate for Payer: Monida First Choice Health	$848.75
Rate for Payer: Monida Montana Health Co-op	$831.25
Rate for Payer: Monida PacificSource	$831.25

ER CARDIOVERSION ELECTIVE EXTERNAL(DEFIB

Facility

$1,537.00

Service Code	HCPCS 92960
Hospital Charge Code	1092960
Hospital Revenue Code	450
Min. Negotiated Rate	$1,075.90
Max. Negotiated Rate	$1,537.00
Rate for Payer: Aetna Commercial	$1,460.15
Rate for Payer: Aetna Medicare	$1,383.30
Rate for Payer: BCBS MT CHIP	$1,383.30
Rate for Payer: BCBS MT Closed Plan Network	$1,460.15
Rate for Payer: BCBS MT HealthLink	$1,383.30
Rate for Payer: BCBS MT Medicare	$1,383.30
Rate for Payer: BCBS MT POS	$1,460.15
Rate for Payer: BCBS MT Traditional	$1,537.00
Rate for Payer: Cash Price	$1,383.30
Rate for Payer: Cigna Commercial	$1,460.15
Rate for Payer: Cigna Medicare	$1,383.30
Rate for Payer: Medicaid All Medicaid	$1,414.04
Rate for Payer: Medicare All Medicare	$1,075.90
Rate for Payer: Monida Allegiance	$1,460.15
Rate for Payer: Monida First Choice Health	$1,490.89
Rate for Payer: Monida Montana Health Co-op	$1,460.15
Rate for Payer: Monida PacificSource	$1,460.15

ER CARDIOVERSION ELECTIVE EXTERNAL(DEFIB

Facility

$1,537.00

Service Code	HCPCS 92960
Hospital Charge Code	1092960
Hospital Revenue Code	450
Min. Negotiated Rate	$1,075.90
Max. Negotiated Rate	$1,537.00
Rate for Payer: Aetna Commercial	$1,460.15
Rate for Payer: Aetna Medicare	$1,383.30
Rate for Payer: BCBS MT CHIP	$1,383.30
Rate for Payer: BCBS MT Closed Plan Network	$1,460.15
Rate for Payer: BCBS MT HealthLink	$1,383.30
Rate for Payer: BCBS MT Medicare	$1,383.30
Rate for Payer: BCBS MT POS	$1,460.15
Rate for Payer: BCBS MT Traditional	$1,537.00
Rate for Payer: Cash Price	$1,383.30
Rate for Payer: Cigna Commercial	$1,460.15
Rate for Payer: Cigna Medicare	$1,383.30
Rate for Payer: Medicaid All Medicaid	$1,414.04
Rate for Payer: Medicare All Medicare	$1,075.90
Rate for Payer: Monida Allegiance	$1,460.15
Rate for Payer: Monida First Choice Health	$1,490.89
Rate for Payer: Monida Montana Health Co-op	$1,460.15
Rate for Payer: Monida PacificSource	$1,460.15

ER CATH ASP NASOTRACHEAL

Facility

$198.00

Service Code	HCPCS 31720
Hospital Charge Code	1031720
Hospital Revenue Code	410
Min. Negotiated Rate	$138.60
Max. Negotiated Rate	$198.00
Rate for Payer: Aetna Commercial	$188.10
Rate for Payer: Aetna Medicare	$178.20
Rate for Payer: BCBS MT CHIP	$178.20
Rate for Payer: BCBS MT Closed Plan Network	$188.10
Rate for Payer: BCBS MT HealthLink	$178.20
Rate for Payer: BCBS MT Medicare	$178.20
Rate for Payer: BCBS MT POS	$188.10
Rate for Payer: BCBS MT Traditional	$198.00
Rate for Payer: Cash Price	$178.20
Rate for Payer: Cigna Commercial	$188.10
Rate for Payer: Cigna Medicare	$178.20
Rate for Payer: Medicaid All Medicaid	$182.16
Rate for Payer: Medicare All Medicare	$138.60
Rate for Payer: Monida Allegiance	$188.10
Rate for Payer: Monida First Choice Health	$192.06
Rate for Payer: Monida Montana Health Co-op	$188.10
Rate for Payer: Monida PacificSource	$188.10

ER CATH ASP NASOTRACHEAL

Facility

$198.00

Service Code	HCPCS 31720
Hospital Charge Code	1031720
Hospital Revenue Code	410
Min. Negotiated Rate	$138.60
Max. Negotiated Rate	$198.00
Rate for Payer: Aetna Commercial	$188.10
Rate for Payer: Aetna Medicare	$178.20
Rate for Payer: BCBS MT CHIP	$178.20
Rate for Payer: BCBS MT Closed Plan Network	$188.10
Rate for Payer: BCBS MT HealthLink	$178.20
Rate for Payer: BCBS MT Medicare	$178.20
Rate for Payer: BCBS MT POS	$188.10
Rate for Payer: BCBS MT Traditional	$198.00
Rate for Payer: Cash Price	$178.20
Rate for Payer: Cigna Commercial	$188.10
Rate for Payer: Cigna Medicare	$178.20
Rate for Payer: Medicaid All Medicaid	$182.16
Rate for Payer: Medicare All Medicare	$138.60
Rate for Payer: Monida Allegiance	$188.10
Rate for Payer: Monida First Choice Health	$192.06
Rate for Payer: Monida Montana Health Co-op	$188.10
Rate for Payer: Monida PacificSource	$188.10

ER CLOSED DISLOCATION ELBOW

Facility

$579.00

Service Code	HCPCS 24600
Hospital Charge Code	1024600
Hospital Revenue Code	450
Min. Negotiated Rate	$405.30
Max. Negotiated Rate	$579.00
Rate for Payer: Aetna Commercial	$550.05
Rate for Payer: Aetna Medicare	$521.10
Rate for Payer: BCBS MT CHIP	$521.10
Rate for Payer: BCBS MT Closed Plan Network	$550.05
Rate for Payer: BCBS MT HealthLink	$521.10
Rate for Payer: BCBS MT Medicare	$521.10
Rate for Payer: BCBS MT POS	$550.05
Rate for Payer: BCBS MT Traditional	$579.00
Rate for Payer: Cash Price	$521.10
Rate for Payer: Cigna Commercial	$550.05
Rate for Payer: Cigna Medicare	$521.10
Rate for Payer: Medicaid All Medicaid	$532.68
Rate for Payer: Medicare All Medicare	$405.30
Rate for Payer: Monida Allegiance	$550.05
Rate for Payer: Monida First Choice Health	$561.63
Rate for Payer: Monida Montana Health Co-op	$550.05
Rate for Payer: Monida PacificSource	$550.05

ER CLOSED DISLOCATION ELBOW

Facility

$579.00

Service Code	HCPCS 24600
Hospital Charge Code	1024600
Hospital Revenue Code	450
Min. Negotiated Rate	$405.30
Max. Negotiated Rate	$579.00
Rate for Payer: Aetna Commercial	$550.05
Rate for Payer: Aetna Medicare	$521.10
Rate for Payer: BCBS MT CHIP	$521.10
Rate for Payer: BCBS MT Closed Plan Network	$550.05
Rate for Payer: BCBS MT HealthLink	$521.10
Rate for Payer: BCBS MT Medicare	$521.10
Rate for Payer: BCBS MT POS	$550.05
Rate for Payer: BCBS MT Traditional	$579.00
Rate for Payer: Cash Price	$521.10
Rate for Payer: Cigna Commercial	$550.05
Rate for Payer: Cigna Medicare	$521.10
Rate for Payer: Medicaid All Medicaid	$532.68
Rate for Payer: Medicare All Medicare	$405.30
Rate for Payer: Monida Allegiance	$550.05
Rate for Payer: Monida First Choice Health	$561.63
Rate for Payer: Monida Montana Health Co-op	$550.05
Rate for Payer: Monida PacificSource	$550.05

ER CLOSED DISLOCATION OF THE TARSAL BONE

Facility

$428.00

Service Code	HCPCS 28540
Hospital Charge Code	1028540
Hospital Revenue Code	450
Min. Negotiated Rate	$299.60
Max. Negotiated Rate	$428.00
Rate for Payer: Aetna Commercial	$406.60
Rate for Payer: Aetna Medicare	$385.20
Rate for Payer: BCBS MT CHIP	$385.20
Rate for Payer: BCBS MT Closed Plan Network	$406.60
Rate for Payer: BCBS MT HealthLink	$385.20
Rate for Payer: BCBS MT Medicare	$385.20
Rate for Payer: BCBS MT POS	$406.60
Rate for Payer: BCBS MT Traditional	$428.00
Rate for Payer: Cash Price	$385.20
Rate for Payer: Cigna Commercial	$406.60
Rate for Payer: Cigna Medicare	$385.20
Rate for Payer: Medicaid All Medicaid	$393.76
Rate for Payer: Medicare All Medicare	$299.60
Rate for Payer: Monida Allegiance	$406.60
Rate for Payer: Monida First Choice Health	$415.16
Rate for Payer: Monida Montana Health Co-op	$406.60
Rate for Payer: Monida PacificSource	$406.60

Know your out-of-pocket cost for care.

All Charges