Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

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

ER CLOSED DISLOCATION OF THE THUMB

Facility

$497.00

Service Code	HCPCS 26641
Hospital Charge Code	1026641
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 CLOSED DISLOCATION OF THE THUMB

Facility

$497.00

Service Code	HCPCS 26641
Hospital Charge Code	1026641
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 CLOSED FX WRIST WITH MANIPULATION

Facility

$722.00

Service Code	HCPCS 25505
Hospital Charge Code	1025505
Hospital Revenue Code	450
Min. Negotiated Rate	$505.40
Max. Negotiated Rate	$722.00
Rate for Payer: Aetna Commercial	$685.90
Rate for Payer: Aetna Medicare	$649.80
Rate for Payer: BCBS MT CHIP	$649.80
Rate for Payer: BCBS MT Closed Plan Network	$685.90
Rate for Payer: BCBS MT HealthLink	$649.80
Rate for Payer: BCBS MT Medicare	$649.80
Rate for Payer: BCBS MT POS	$685.90
Rate for Payer: BCBS MT Traditional	$722.00
Rate for Payer: Cash Price	$649.80
Rate for Payer: Cigna Commercial	$685.90
Rate for Payer: Cigna Medicare	$649.80
Rate for Payer: Medicaid All Medicaid	$664.24
Rate for Payer: Medicare All Medicare	$505.40
Rate for Payer: Monida Allegiance	$685.90
Rate for Payer: Monida First Choice Health	$700.34
Rate for Payer: Monida Montana Health Co-op	$685.90
Rate for Payer: Monida PacificSource	$685.90

ER CLOSED FX WRIST WITH MANIPULATION

Facility

$722.00

Service Code	HCPCS 25505
Hospital Charge Code	1025505
Hospital Revenue Code	450
Min. Negotiated Rate	$505.40
Max. Negotiated Rate	$722.00
Rate for Payer: Aetna Commercial	$685.90
Rate for Payer: Aetna Medicare	$649.80
Rate for Payer: BCBS MT CHIP	$649.80
Rate for Payer: BCBS MT Closed Plan Network	$685.90
Rate for Payer: BCBS MT HealthLink	$649.80
Rate for Payer: BCBS MT Medicare	$649.80
Rate for Payer: BCBS MT POS	$685.90
Rate for Payer: BCBS MT Traditional	$722.00
Rate for Payer: Cash Price	$649.80
Rate for Payer: Cigna Commercial	$685.90
Rate for Payer: Cigna Medicare	$649.80
Rate for Payer: Medicaid All Medicaid	$664.24
Rate for Payer: Medicare All Medicare	$505.40
Rate for Payer: Monida Allegiance	$685.90
Rate for Payer: Monida First Choice Health	$700.34
Rate for Payer: Monida Montana Health Co-op	$685.90
Rate for Payer: Monida PacificSource	$685.90

ER CLOSED KNEE DISLOCATION W/O ANESTHIA

Facility

$579.00

Service Code	HCPCS 27550
Hospital Charge Code	1027750
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 KNEE DISLOCATION W/O ANESTHIA

Facility

$579.00

Service Code	HCPCS 27550
Hospital Charge Code	1027750
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 TX NOSE FX W/O STAB

Facility

$1,042.00

Service Code	HCPCS 21315
Hospital Charge Code	1021315
Hospital Revenue Code	450
Min. Negotiated Rate	$729.40
Max. Negotiated Rate	$1,042.00
Rate for Payer: Aetna Commercial	$989.90
Rate for Payer: Aetna Medicare	$937.80
Rate for Payer: BCBS MT CHIP	$937.80
Rate for Payer: BCBS MT Closed Plan Network	$989.90
Rate for Payer: BCBS MT HealthLink	$937.80
Rate for Payer: BCBS MT Medicare	$937.80
Rate for Payer: BCBS MT POS	$989.90
Rate for Payer: BCBS MT Traditional	$1,042.00
Rate for Payer: Cash Price	$937.80
Rate for Payer: Cigna Commercial	$989.90
Rate for Payer: Cigna Medicare	$937.80
Rate for Payer: Medicaid All Medicaid	$958.64
Rate for Payer: Medicare All Medicare	$729.40
Rate for Payer: Monida Allegiance	$989.90
Rate for Payer: Monida First Choice Health	$1,010.74
Rate for Payer: Monida Montana Health Co-op	$989.90
Rate for Payer: Monida PacificSource	$989.90

ER CLOSED TX NOSE FX W/O STAB

Facility

$1,042.00

Service Code	HCPCS 21315
Hospital Charge Code	1021315
Hospital Revenue Code	450
Min. Negotiated Rate	$729.40
Max. Negotiated Rate	$1,042.00
Rate for Payer: Aetna Commercial	$989.90
Rate for Payer: Aetna Medicare	$937.80
Rate for Payer: BCBS MT CHIP	$937.80
Rate for Payer: BCBS MT Closed Plan Network	$989.90
Rate for Payer: BCBS MT HealthLink	$937.80
Rate for Payer: BCBS MT Medicare	$937.80
Rate for Payer: BCBS MT POS	$989.90
Rate for Payer: BCBS MT Traditional	$1,042.00
Rate for Payer: Cash Price	$937.80
Rate for Payer: Cigna Commercial	$989.90
Rate for Payer: Cigna Medicare	$937.80
Rate for Payer: Medicaid All Medicaid	$958.64
Rate for Payer: Medicare All Medicare	$729.40
Rate for Payer: Monida Allegiance	$989.90
Rate for Payer: Monida First Choice Health	$1,010.74
Rate for Payer: Monida Montana Health Co-op	$989.90
Rate for Payer: Monida PacificSource	$989.90

ER CLSD TRT DISLC OF THE FINGER W/MANI

Facility

$510.00

Service Code	HCPCS 26700
Hospital Charge Code	1026700
Hospital Revenue Code	450
Min. Negotiated Rate	$357.00
Max. Negotiated Rate	$510.00
Rate for Payer: Aetna Commercial	$484.50
Rate for Payer: Aetna Medicare	$459.00
Rate for Payer: BCBS MT CHIP	$459.00
Rate for Payer: BCBS MT Closed Plan Network	$484.50
Rate for Payer: BCBS MT HealthLink	$459.00
Rate for Payer: BCBS MT Medicare	$459.00
Rate for Payer: BCBS MT POS	$484.50
Rate for Payer: BCBS MT Traditional	$510.00
Rate for Payer: Cash Price	$459.00
Rate for Payer: Cigna Commercial	$484.50
Rate for Payer: Cigna Medicare	$459.00
Rate for Payer: Medicaid All Medicaid	$469.20
Rate for Payer: Medicare All Medicare	$357.00
Rate for Payer: Monida Allegiance	$484.50
Rate for Payer: Monida First Choice Health	$494.70
Rate for Payer: Monida Montana Health Co-op	$484.50
Rate for Payer: Monida PacificSource	$484.50

ER CLSD TRT DISLC OF THE FINGER W/MANI

Facility

$510.00

Service Code	HCPCS 26700
Hospital Charge Code	1026700
Hospital Revenue Code	450
Min. Negotiated Rate	$357.00
Max. Negotiated Rate	$510.00
Rate for Payer: Aetna Commercial	$484.50
Rate for Payer: Aetna Medicare	$459.00
Rate for Payer: BCBS MT CHIP	$459.00
Rate for Payer: BCBS MT Closed Plan Network	$484.50
Rate for Payer: BCBS MT HealthLink	$459.00
Rate for Payer: BCBS MT Medicare	$459.00
Rate for Payer: BCBS MT POS	$484.50
Rate for Payer: BCBS MT Traditional	$510.00
Rate for Payer: Cash Price	$459.00
Rate for Payer: Cigna Commercial	$484.50
Rate for Payer: Cigna Medicare	$459.00
Rate for Payer: Medicaid All Medicaid	$469.20
Rate for Payer: Medicare All Medicare	$357.00
Rate for Payer: Monida Allegiance	$484.50
Rate for Payer: Monida First Choice Health	$494.70
Rate for Payer: Monida Montana Health Co-op	$484.50
Rate for Payer: Monida PacificSource	$484.50

ER CLSD TX HUM SHAFT FRAC W/MANIP 24505

Facility

$563.00

Service Code	HCPCS 24505
Hospital Charge Code	1024505
Hospital Revenue Code	450
Min. Negotiated Rate	$394.10
Max. Negotiated Rate	$563.00
Rate for Payer: Aetna Commercial	$534.85
Rate for Payer: Aetna Medicare	$506.70
Rate for Payer: BCBS MT CHIP	$506.70
Rate for Payer: BCBS MT Closed Plan Network	$534.85
Rate for Payer: BCBS MT HealthLink	$506.70
Rate for Payer: BCBS MT Medicare	$506.70
Rate for Payer: BCBS MT POS	$534.85
Rate for Payer: BCBS MT Traditional	$563.00
Rate for Payer: Cash Price	$506.70
Rate for Payer: Cigna Commercial	$534.85
Rate for Payer: Cigna Medicare	$506.70
Rate for Payer: Medicaid All Medicaid	$517.96
Rate for Payer: Medicare All Medicare	$394.10
Rate for Payer: Monida Allegiance	$534.85
Rate for Payer: Monida First Choice Health	$546.11
Rate for Payer: Monida Montana Health Co-op	$534.85
Rate for Payer: Monida PacificSource	$534.85

ER CLSD TX HUM SHAFT FRAC W/MANIP 24505

Facility

$563.00

Service Code	HCPCS 24505
Hospital Charge Code	1024505
Hospital Revenue Code	450
Min. Negotiated Rate	$394.10
Max. Negotiated Rate	$563.00
Rate for Payer: Aetna Commercial	$534.85
Rate for Payer: Aetna Medicare	$506.70
Rate for Payer: BCBS MT CHIP	$506.70
Rate for Payer: BCBS MT Closed Plan Network	$534.85
Rate for Payer: BCBS MT HealthLink	$506.70
Rate for Payer: BCBS MT Medicare	$506.70
Rate for Payer: BCBS MT POS	$534.85
Rate for Payer: BCBS MT Traditional	$563.00
Rate for Payer: Cash Price	$506.70
Rate for Payer: Cigna Commercial	$534.85
Rate for Payer: Cigna Medicare	$506.70
Rate for Payer: Medicaid All Medicaid	$517.96
Rate for Payer: Medicare All Medicare	$394.10
Rate for Payer: Monida Allegiance	$534.85
Rate for Payer: Monida First Choice Health	$546.11
Rate for Payer: Monida Montana Health Co-op	$534.85
Rate for Payer: Monida PacificSource	$534.85

ER CLTX OF FRAC OF THE FINGER EACH W/WO

Facility

$533.00

Service Code	HCPCS 26725
Hospital Charge Code	1026725
Hospital Revenue Code	450
Min. Negotiated Rate	$373.10
Max. Negotiated Rate	$533.00
Rate for Payer: Aetna Commercial	$506.35
Rate for Payer: Aetna Medicare	$479.70
Rate for Payer: BCBS MT CHIP	$479.70
Rate for Payer: BCBS MT Closed Plan Network	$506.35
Rate for Payer: BCBS MT HealthLink	$479.70
Rate for Payer: BCBS MT Medicare	$479.70
Rate for Payer: BCBS MT POS	$506.35
Rate for Payer: BCBS MT Traditional	$533.00
Rate for Payer: Cash Price	$479.70
Rate for Payer: Cigna Commercial	$506.35
Rate for Payer: Cigna Medicare	$479.70
Rate for Payer: Medicaid All Medicaid	$490.36
Rate for Payer: Medicare All Medicare	$373.10
Rate for Payer: Monida Allegiance	$506.35
Rate for Payer: Monida First Choice Health	$517.01
Rate for Payer: Monida Montana Health Co-op	$506.35
Rate for Payer: Monida PacificSource	$506.35

ER CLTX OF FRAC OF THE FINGER EACH W/WO

Facility

$533.00

Service Code	HCPCS 26725
Hospital Charge Code	1026725
Hospital Revenue Code	450
Min. Negotiated Rate	$373.10
Max. Negotiated Rate	$533.00
Rate for Payer: Aetna Commercial	$506.35
Rate for Payer: Aetna Medicare	$479.70
Rate for Payer: BCBS MT CHIP	$479.70
Rate for Payer: BCBS MT Closed Plan Network	$506.35
Rate for Payer: BCBS MT HealthLink	$479.70
Rate for Payer: BCBS MT Medicare	$479.70
Rate for Payer: BCBS MT POS	$506.35
Rate for Payer: BCBS MT Traditional	$533.00
Rate for Payer: Cash Price	$479.70
Rate for Payer: Cigna Commercial	$506.35
Rate for Payer: Cigna Medicare	$479.70
Rate for Payer: Medicaid All Medicaid	$490.36
Rate for Payer: Medicare All Medicare	$373.10
Rate for Payer: Monida Allegiance	$506.35
Rate for Payer: Monida First Choice Health	$517.01
Rate for Payer: Monida Montana Health Co-op	$506.35
Rate for Payer: Monida PacificSource	$506.35

ER DRAINAGE ABSC,CYST DENTOALVEOLAR41800

Facility

$547.00

Service Code	HCPCS 41800
Hospital Charge Code	1041800
Hospital Revenue Code	450
Min. Negotiated Rate	$382.90
Max. Negotiated Rate	$547.00
Rate for Payer: Aetna Commercial	$519.65
Rate for Payer: Aetna Medicare	$492.30
Rate for Payer: BCBS MT CHIP	$492.30
Rate for Payer: BCBS MT Closed Plan Network	$519.65
Rate for Payer: BCBS MT HealthLink	$492.30
Rate for Payer: BCBS MT Medicare	$492.30
Rate for Payer: BCBS MT POS	$519.65
Rate for Payer: BCBS MT Traditional	$547.00
Rate for Payer: Cash Price	$492.30
Rate for Payer: Cigna Commercial	$519.65
Rate for Payer: Cigna Medicare	$492.30
Rate for Payer: Medicaid All Medicaid	$503.24
Rate for Payer: Medicare All Medicare	$382.90
Rate for Payer: Monida Allegiance	$519.65
Rate for Payer: Monida First Choice Health	$530.59
Rate for Payer: Monida Montana Health Co-op	$519.65
Rate for Payer: Monida PacificSource	$519.65

ER DRAINAGE ABSC,CYST DENTOALVEOLAR41800

Facility

$547.00

Service Code	HCPCS 41800
Hospital Charge Code	1041800
Hospital Revenue Code	450
Min. Negotiated Rate	$382.90
Max. Negotiated Rate	$547.00
Rate for Payer: Aetna Commercial	$519.65
Rate for Payer: Aetna Medicare	$492.30
Rate for Payer: BCBS MT CHIP	$492.30
Rate for Payer: BCBS MT Closed Plan Network	$519.65
Rate for Payer: BCBS MT HealthLink	$492.30
Rate for Payer: BCBS MT Medicare	$492.30
Rate for Payer: BCBS MT POS	$519.65
Rate for Payer: BCBS MT Traditional	$547.00
Rate for Payer: Cash Price	$492.30
Rate for Payer: Cigna Commercial	$519.65
Rate for Payer: Cigna Medicare	$492.30
Rate for Payer: Medicaid All Medicaid	$503.24
Rate for Payer: Medicare All Medicare	$382.90
Rate for Payer: Monida Allegiance	$519.65
Rate for Payer: Monida First Choice Health	$530.59
Rate for Payer: Monida Montana Health Co-op	$519.65
Rate for Payer: Monida PacificSource	$519.65

ER DRAINAGE OF BARTHOLINS GLAND ABSCESS

Facility

$441.00

Service Code	HCPCS 56420
Hospital Charge Code	1056420
Hospital Revenue Code	450
Min. Negotiated Rate	$308.70
Max. Negotiated Rate	$441.00
Rate for Payer: Aetna Commercial	$418.95
Rate for Payer: Aetna Medicare	$396.90
Rate for Payer: BCBS MT CHIP	$396.90
Rate for Payer: BCBS MT Closed Plan Network	$418.95
Rate for Payer: BCBS MT HealthLink	$396.90
Rate for Payer: BCBS MT Medicare	$396.90
Rate for Payer: BCBS MT POS	$418.95
Rate for Payer: BCBS MT Traditional	$441.00
Rate for Payer: Cash Price	$396.90
Rate for Payer: Cigna Commercial	$418.95
Rate for Payer: Cigna Medicare	$396.90
Rate for Payer: Medicaid All Medicaid	$405.72
Rate for Payer: Medicare All Medicare	$308.70
Rate for Payer: Monida Allegiance	$418.95
Rate for Payer: Monida First Choice Health	$427.77
Rate for Payer: Monida Montana Health Co-op	$418.95
Rate for Payer: Monida PacificSource	$418.95

ER DRAINAGE OF BARTHOLINS GLAND ABSCESS

Facility

$441.00

Service Code	HCPCS 56420
Hospital Charge Code	1056420
Hospital Revenue Code	450
Min. Negotiated Rate	$308.70
Max. Negotiated Rate	$441.00
Rate for Payer: Aetna Commercial	$418.95
Rate for Payer: Aetna Medicare	$396.90
Rate for Payer: BCBS MT CHIP	$396.90
Rate for Payer: BCBS MT Closed Plan Network	$418.95
Rate for Payer: BCBS MT HealthLink	$396.90
Rate for Payer: BCBS MT Medicare	$396.90
Rate for Payer: BCBS MT POS	$418.95
Rate for Payer: BCBS MT Traditional	$441.00
Rate for Payer: Cash Price	$396.90
Rate for Payer: Cigna Commercial	$418.95
Rate for Payer: Cigna Medicare	$396.90
Rate for Payer: Medicaid All Medicaid	$405.72
Rate for Payer: Medicare All Medicare	$308.70
Rate for Payer: Monida Allegiance	$418.95
Rate for Payer: Monida First Choice Health	$427.77
Rate for Payer: Monida Montana Health Co-op	$418.95
Rate for Payer: Monida PacificSource	$418.95

ER DRAIN BLOOD FROM UNDER NAIL

Facility

$175.00

Service Code	HCPCS 11740
Hospital Charge Code	1011740
Hospital Revenue Code	450
Min. Negotiated Rate	$122.50
Max. Negotiated Rate	$175.00
Rate for Payer: Aetna Commercial	$166.25
Rate for Payer: Aetna Medicare	$157.50
Rate for Payer: BCBS MT CHIP	$157.50
Rate for Payer: BCBS MT Closed Plan Network	$166.25
Rate for Payer: BCBS MT HealthLink	$157.50
Rate for Payer: BCBS MT Medicare	$157.50
Rate for Payer: BCBS MT POS	$166.25
Rate for Payer: BCBS MT Traditional	$175.00
Rate for Payer: Cash Price	$157.50
Rate for Payer: Cigna Commercial	$166.25
Rate for Payer: Cigna Medicare	$157.50
Rate for Payer: Medicaid All Medicaid	$161.00
Rate for Payer: Medicare All Medicare	$122.50
Rate for Payer: Monida Allegiance	$166.25
Rate for Payer: Monida First Choice Health	$169.75
Rate for Payer: Monida Montana Health Co-op	$166.25
Rate for Payer: Monida PacificSource	$166.25

ER DRAIN BLOOD FROM UNDER NAIL

Facility

$175.00

Service Code	HCPCS 11740
Hospital Charge Code	1011740
Hospital Revenue Code	450
Min. Negotiated Rate	$122.50
Max. Negotiated Rate	$175.00
Rate for Payer: Aetna Commercial	$166.25
Rate for Payer: Aetna Medicare	$157.50
Rate for Payer: BCBS MT CHIP	$157.50
Rate for Payer: BCBS MT Closed Plan Network	$166.25
Rate for Payer: BCBS MT HealthLink	$157.50
Rate for Payer: BCBS MT Medicare	$157.50
Rate for Payer: BCBS MT POS	$166.25
Rate for Payer: BCBS MT Traditional	$175.00
Rate for Payer: Cash Price	$157.50
Rate for Payer: Cigna Commercial	$166.25
Rate for Payer: Cigna Medicare	$157.50
Rate for Payer: Medicaid All Medicaid	$161.00
Rate for Payer: Medicare All Medicare	$122.50
Rate for Payer: Monida Allegiance	$166.25
Rate for Payer: Monida First Choice Health	$169.75
Rate for Payer: Monida Montana Health Co-op	$166.25
Rate for Payer: Monida PacificSource	$166.25

ER DRESS/DEBRIDE BURN >10%TOTAL LARGE

Facility

$525.00

Service Code	HCPCS 16030
Hospital Charge Code	1016030
Hospital Revenue Code	450
Min. Negotiated Rate	$367.50
Max. Negotiated Rate	$525.00
Rate for Payer: Aetna Commercial	$498.75
Rate for Payer: Aetna Medicare	$472.50
Rate for Payer: BCBS MT CHIP	$472.50
Rate for Payer: BCBS MT Closed Plan Network	$498.75
Rate for Payer: BCBS MT HealthLink	$472.50
Rate for Payer: BCBS MT Medicare	$472.50
Rate for Payer: BCBS MT POS	$498.75
Rate for Payer: BCBS MT Traditional	$525.00
Rate for Payer: Cash Price	$472.50
Rate for Payer: Cigna Commercial	$498.75
Rate for Payer: Cigna Medicare	$472.50
Rate for Payer: Medicaid All Medicaid	$483.00
Rate for Payer: Medicare All Medicare	$367.50
Rate for Payer: Monida Allegiance	$498.75
Rate for Payer: Monida First Choice Health	$509.25
Rate for Payer: Monida Montana Health Co-op	$498.75
Rate for Payer: Monida PacificSource	$498.75

ER DRESS/DEBRIDE BURN >10%TOTAL LARGE

Facility

$525.00

Service Code	HCPCS 16030
Hospital Charge Code	1016030
Hospital Revenue Code	450
Min. Negotiated Rate	$367.50
Max. Negotiated Rate	$525.00
Rate for Payer: Aetna Commercial	$498.75
Rate for Payer: Aetna Medicare	$472.50
Rate for Payer: BCBS MT CHIP	$472.50
Rate for Payer: BCBS MT Closed Plan Network	$498.75
Rate for Payer: BCBS MT HealthLink	$472.50
Rate for Payer: BCBS MT Medicare	$472.50
Rate for Payer: BCBS MT POS	$498.75
Rate for Payer: BCBS MT Traditional	$525.00
Rate for Payer: Cash Price	$472.50
Rate for Payer: Cigna Commercial	$498.75
Rate for Payer: Cigna Medicare	$472.50
Rate for Payer: Medicaid All Medicaid	$483.00
Rate for Payer: Medicare All Medicare	$367.50
Rate for Payer: Monida Allegiance	$498.75
Rate for Payer: Monida First Choice Health	$509.25
Rate for Payer: Monida Montana Health Co-op	$498.75
Rate for Payer: Monida PacificSource	$498.75

ER DRESS/DEBRIDE PART-THICK BURNS >5%

Facility

$387.00

Service Code	HCPCS 16020
Hospital Charge Code	1016020
Hospital Revenue Code	450
Min. Negotiated Rate	$270.90
Max. Negotiated Rate	$387.00
Rate for Payer: Aetna Commercial	$367.65
Rate for Payer: Aetna Medicare	$348.30
Rate for Payer: BCBS MT CHIP	$348.30
Rate for Payer: BCBS MT Closed Plan Network	$367.65
Rate for Payer: BCBS MT HealthLink	$348.30
Rate for Payer: BCBS MT Medicare	$348.30
Rate for Payer: BCBS MT POS	$367.65
Rate for Payer: BCBS MT Traditional	$387.00
Rate for Payer: Cash Price	$348.30
Rate for Payer: Cigna Commercial	$367.65
Rate for Payer: Cigna Medicare	$348.30
Rate for Payer: Medicaid All Medicaid	$356.04
Rate for Payer: Medicare All Medicare	$270.90
Rate for Payer: Monida Allegiance	$367.65
Rate for Payer: Monida First Choice Health	$375.39
Rate for Payer: Monida Montana Health Co-op	$367.65
Rate for Payer: Monida PacificSource	$367.65

ER DRESS/DEBRIDE PART-THICK BURNS >5%

Facility

$387.00

Service Code	HCPCS 16020
Hospital Charge Code	1016020
Hospital Revenue Code	450
Min. Negotiated Rate	$270.90
Max. Negotiated Rate	$387.00
Rate for Payer: Aetna Commercial	$367.65
Rate for Payer: Aetna Medicare	$348.30
Rate for Payer: BCBS MT CHIP	$348.30
Rate for Payer: BCBS MT Closed Plan Network	$367.65
Rate for Payer: BCBS MT HealthLink	$348.30
Rate for Payer: BCBS MT Medicare	$348.30
Rate for Payer: BCBS MT POS	$367.65
Rate for Payer: BCBS MT Traditional	$387.00
Rate for Payer: Cash Price	$348.30
Rate for Payer: Cigna Commercial	$367.65
Rate for Payer: Cigna Medicare	$348.30
Rate for Payer: Medicaid All Medicaid	$356.04
Rate for Payer: Medicare All Medicare	$270.90
Rate for Payer: Monida Allegiance	$367.65
Rate for Payer: Monida First Choice Health	$375.39
Rate for Payer: Monida Montana Health Co-op	$367.65
Rate for Payer: Monida PacificSource	$367.65

Know your out-of-pocket cost for care.

All Charges