Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

ERPAK ONDANSETRON ODT [4 MG] 6 TAB PACKS

Facility

$48.00

Service Code	HCPCS J3490
Hospital Charge Code	3000162
Hospital Revenue Code	250
Min. Negotiated Rate	$33.60
Max. Negotiated Rate	$48.00
Rate for Payer: Aetna Commercial	$45.60
Rate for Payer: Aetna Medicare	$43.20
Rate for Payer: BCBS MT CHIP	$43.20
Rate for Payer: BCBS MT Closed Plan Network	$45.60
Rate for Payer: BCBS MT HealthLink	$43.20
Rate for Payer: BCBS MT Medicare	$43.20
Rate for Payer: BCBS MT POS	$45.60
Rate for Payer: BCBS MT Traditional	$48.00
Rate for Payer: Cash Price	$43.20
Rate for Payer: Cigna Commercial	$45.60
Rate for Payer: Cigna Medicare	$43.20
Rate for Payer: Medicaid All Medicaid	$44.16
Rate for Payer: Medicare All Medicare	$33.60
Rate for Payer: Monida Allegiance	$45.60
Rate for Payer: Monida First Choice Health	$46.56
Rate for Payer: Monida Montana Health Co-op	$45.60
Rate for Payer: Monida PacificSource	$45.60

ERPAK TRAMADOL TAB [50 MG] 4 TAB PACK

Facility

$21.00

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

ERPAK TRAMADOL TAB [50 MG] 4 TAB PACK

Facility

$21.00

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

ER PLACE NEEDLE INFUSION INTRAOSSEOUS

Facility

$375.00

Service Code	HCPCS 36680
Hospital Charge Code	1033680
Hospital Revenue Code	450
Min. Negotiated Rate	$262.50
Max. Negotiated Rate	$375.00
Rate for Payer: Aetna Commercial	$356.25
Rate for Payer: Aetna Medicare	$337.50
Rate for Payer: BCBS MT CHIP	$337.50
Rate for Payer: BCBS MT Closed Plan Network	$356.25
Rate for Payer: BCBS MT HealthLink	$337.50
Rate for Payer: BCBS MT Medicare	$337.50
Rate for Payer: BCBS MT POS	$356.25
Rate for Payer: BCBS MT Traditional	$375.00
Rate for Payer: Cash Price	$337.50
Rate for Payer: Cigna Commercial	$356.25
Rate for Payer: Cigna Medicare	$337.50
Rate for Payer: Medicaid All Medicaid	$345.00
Rate for Payer: Medicare All Medicare	$262.50
Rate for Payer: Monida Allegiance	$356.25
Rate for Payer: Monida First Choice Health	$363.75
Rate for Payer: Monida Montana Health Co-op	$356.25
Rate for Payer: Monida PacificSource	$356.25

ER PLACE NEEDLE INFUSION INTRAOSSEOUS

Facility

$375.00

Service Code	HCPCS 36680
Hospital Charge Code	1033680
Hospital Revenue Code	450
Min. Negotiated Rate	$262.50
Max. Negotiated Rate	$375.00
Rate for Payer: Aetna Commercial	$356.25
Rate for Payer: Aetna Medicare	$337.50
Rate for Payer: BCBS MT CHIP	$337.50
Rate for Payer: BCBS MT Closed Plan Network	$356.25
Rate for Payer: BCBS MT HealthLink	$337.50
Rate for Payer: BCBS MT Medicare	$337.50
Rate for Payer: BCBS MT POS	$356.25
Rate for Payer: BCBS MT Traditional	$375.00
Rate for Payer: Cash Price	$337.50
Rate for Payer: Cigna Commercial	$356.25
Rate for Payer: Cigna Medicare	$337.50
Rate for Payer: Medicaid All Medicaid	$345.00
Rate for Payer: Medicare All Medicare	$262.50
Rate for Payer: Monida Allegiance	$356.25
Rate for Payer: Monida First Choice Health	$363.75
Rate for Payer: Monida Montana Health Co-op	$356.25
Rate for Payer: Monida PacificSource	$356.25

ER REDUCTION OF RECTAL PROLAPSE

Facility

$863.00

Service Code	HCPCS 45900
Hospital Charge Code	1045900
Hospital Revenue Code	450
Min. Negotiated Rate	$604.10
Max. Negotiated Rate	$863.00
Rate for Payer: Aetna Commercial	$819.85
Rate for Payer: Aetna Medicare	$776.70
Rate for Payer: BCBS MT CHIP	$776.70
Rate for Payer: BCBS MT Closed Plan Network	$819.85
Rate for Payer: BCBS MT HealthLink	$776.70
Rate for Payer: BCBS MT Medicare	$776.70
Rate for Payer: BCBS MT POS	$819.85
Rate for Payer: BCBS MT Traditional	$863.00
Rate for Payer: Cash Price	$776.70
Rate for Payer: Cigna Commercial	$819.85
Rate for Payer: Cigna Medicare	$776.70
Rate for Payer: Medicaid All Medicaid	$793.96
Rate for Payer: Medicare All Medicare	$604.10
Rate for Payer: Monida Allegiance	$819.85
Rate for Payer: Monida First Choice Health	$837.11
Rate for Payer: Monida Montana Health Co-op	$819.85
Rate for Payer: Monida PacificSource	$819.85

ER REDUCTION OF RECTAL PROLAPSE

Facility

$863.00

Service Code	HCPCS 45900
Hospital Charge Code	1045900
Hospital Revenue Code	450
Min. Negotiated Rate	$604.10
Max. Negotiated Rate	$863.00
Rate for Payer: Aetna Commercial	$819.85
Rate for Payer: Aetna Medicare	$776.70
Rate for Payer: BCBS MT CHIP	$776.70
Rate for Payer: BCBS MT Closed Plan Network	$819.85
Rate for Payer: BCBS MT HealthLink	$776.70
Rate for Payer: BCBS MT Medicare	$776.70
Rate for Payer: BCBS MT POS	$819.85
Rate for Payer: BCBS MT Traditional	$863.00
Rate for Payer: Cash Price	$776.70
Rate for Payer: Cigna Commercial	$819.85
Rate for Payer: Cigna Medicare	$776.70
Rate for Payer: Medicaid All Medicaid	$793.96
Rate for Payer: Medicare All Medicare	$604.10
Rate for Payer: Monida Allegiance	$819.85
Rate for Payer: Monida First Choice Health	$837.11
Rate for Payer: Monida Montana Health Co-op	$819.85
Rate for Payer: Monida PacificSource	$819.85

ER REMOVAL OF NAIL PLATE

Facility

$301.00

Service Code	HCPCS 11730
Hospital Charge Code	1011730
Hospital Revenue Code	450
Min. Negotiated Rate	$210.70
Max. Negotiated Rate	$301.00
Rate for Payer: Aetna Commercial	$285.95
Rate for Payer: Aetna Medicare	$270.90
Rate for Payer: BCBS MT CHIP	$270.90
Rate for Payer: BCBS MT Closed Plan Network	$285.95
Rate for Payer: BCBS MT HealthLink	$270.90
Rate for Payer: BCBS MT Medicare	$270.90
Rate for Payer: BCBS MT POS	$285.95
Rate for Payer: BCBS MT Traditional	$301.00
Rate for Payer: Cash Price	$270.90
Rate for Payer: Cigna Commercial	$285.95
Rate for Payer: Cigna Medicare	$270.90
Rate for Payer: Medicaid All Medicaid	$276.92
Rate for Payer: Medicare All Medicare	$210.70
Rate for Payer: Monida Allegiance	$285.95
Rate for Payer: Monida First Choice Health	$291.97
Rate for Payer: Monida Montana Health Co-op	$285.95
Rate for Payer: Monida PacificSource	$285.95

ER REMOVAL OF NAIL PLATE

Facility

$301.00

Service Code	HCPCS 11730
Hospital Charge Code	1011730
Hospital Revenue Code	450
Min. Negotiated Rate	$210.70
Max. Negotiated Rate	$301.00
Rate for Payer: Aetna Commercial	$285.95
Rate for Payer: Aetna Medicare	$270.90
Rate for Payer: BCBS MT CHIP	$270.90
Rate for Payer: BCBS MT Closed Plan Network	$285.95
Rate for Payer: BCBS MT HealthLink	$270.90
Rate for Payer: BCBS MT Medicare	$270.90
Rate for Payer: BCBS MT POS	$285.95
Rate for Payer: BCBS MT Traditional	$301.00
Rate for Payer: Cash Price	$270.90
Rate for Payer: Cigna Commercial	$285.95
Rate for Payer: Cigna Medicare	$270.90
Rate for Payer: Medicaid All Medicaid	$276.92
Rate for Payer: Medicare All Medicare	$210.70
Rate for Payer: Monida Allegiance	$285.95
Rate for Payer: Monida First Choice Health	$291.97
Rate for Payer: Monida Montana Health Co-op	$285.95
Rate for Payer: Monida PacificSource	$285.95

ER REMOVE FB DEEP OR COMLICATED

Facility

$3,792.00

Service Code	HCPCS 20525
Hospital Charge Code	1020525
Hospital Revenue Code	450
Min. Negotiated Rate	$2,654.40
Max. Negotiated Rate	$3,792.00
Rate for Payer: Aetna Commercial	$3,602.40
Rate for Payer: Aetna Medicare	$3,412.80
Rate for Payer: BCBS MT CHIP	$3,412.80
Rate for Payer: BCBS MT Closed Plan Network	$3,602.40
Rate for Payer: BCBS MT HealthLink	$3,412.80
Rate for Payer: BCBS MT Medicare	$3,412.80
Rate for Payer: BCBS MT POS	$3,602.40
Rate for Payer: BCBS MT Traditional	$3,792.00
Rate for Payer: Cash Price	$3,412.80
Rate for Payer: Cigna Commercial	$3,602.40
Rate for Payer: Cigna Medicare	$3,412.80
Rate for Payer: Medicaid All Medicaid	$3,488.64
Rate for Payer: Medicare All Medicare	$2,654.40
Rate for Payer: Monida Allegiance	$3,602.40
Rate for Payer: Monida First Choice Health	$3,678.24
Rate for Payer: Monida Montana Health Co-op	$3,602.40
Rate for Payer: Monida PacificSource	$3,602.40

ER REMOVE FB DEEP OR COMLICATED

Facility

$3,792.00

Service Code	HCPCS 20525
Hospital Charge Code	1020525
Hospital Revenue Code	450
Min. Negotiated Rate	$2,654.40
Max. Negotiated Rate	$3,792.00
Rate for Payer: Aetna Commercial	$3,602.40
Rate for Payer: Aetna Medicare	$3,412.80
Rate for Payer: BCBS MT CHIP	$3,412.80
Rate for Payer: BCBS MT Closed Plan Network	$3,602.40
Rate for Payer: BCBS MT HealthLink	$3,412.80
Rate for Payer: BCBS MT Medicare	$3,412.80
Rate for Payer: BCBS MT POS	$3,602.40
Rate for Payer: BCBS MT Traditional	$3,792.00
Rate for Payer: Cash Price	$3,412.80
Rate for Payer: Cigna Commercial	$3,602.40
Rate for Payer: Cigna Medicare	$3,412.80
Rate for Payer: Medicaid All Medicaid	$3,488.64
Rate for Payer: Medicare All Medicare	$2,654.40
Rate for Payer: Monida Allegiance	$3,602.40
Rate for Payer: Monida First Choice Health	$3,678.24
Rate for Payer: Monida Montana Health Co-op	$3,602.40
Rate for Payer: Monida PacificSource	$3,602.40

ER REMOVE FB MUSCLE/TENDON SHEATH SIMPLE

Facility

$1,847.00

Service Code	HCPCS 20520
Hospital Charge Code	1020520
Hospital Revenue Code	450
Min. Negotiated Rate	$1,292.90
Max. Negotiated Rate	$1,847.00
Rate for Payer: Aetna Commercial	$1,754.65
Rate for Payer: Aetna Medicare	$1,662.30
Rate for Payer: BCBS MT CHIP	$1,662.30
Rate for Payer: BCBS MT Closed Plan Network	$1,754.65
Rate for Payer: BCBS MT HealthLink	$1,662.30
Rate for Payer: BCBS MT Medicare	$1,662.30
Rate for Payer: BCBS MT POS	$1,754.65
Rate for Payer: BCBS MT Traditional	$1,847.00
Rate for Payer: Cash Price	$1,662.30
Rate for Payer: Cigna Commercial	$1,754.65
Rate for Payer: Cigna Medicare	$1,662.30
Rate for Payer: Medicaid All Medicaid	$1,699.24
Rate for Payer: Medicare All Medicare	$1,292.90
Rate for Payer: Monida Allegiance	$1,754.65
Rate for Payer: Monida First Choice Health	$1,791.59
Rate for Payer: Monida Montana Health Co-op	$1,754.65
Rate for Payer: Monida PacificSource	$1,754.65

ER REMOVE FB MUSCLE/TENDON SHEATH SIMPLE

Facility

$1,847.00

Service Code	HCPCS 20520
Hospital Charge Code	1020520
Hospital Revenue Code	450
Min. Negotiated Rate	$1,292.90
Max. Negotiated Rate	$1,847.00
Rate for Payer: Aetna Commercial	$1,754.65
Rate for Payer: Aetna Medicare	$1,662.30
Rate for Payer: BCBS MT CHIP	$1,662.30
Rate for Payer: BCBS MT Closed Plan Network	$1,754.65
Rate for Payer: BCBS MT HealthLink	$1,662.30
Rate for Payer: BCBS MT Medicare	$1,662.30
Rate for Payer: BCBS MT POS	$1,754.65
Rate for Payer: BCBS MT Traditional	$1,847.00
Rate for Payer: Cash Price	$1,662.30
Rate for Payer: Cigna Commercial	$1,754.65
Rate for Payer: Cigna Medicare	$1,662.30
Rate for Payer: Medicaid All Medicaid	$1,699.24
Rate for Payer: Medicare All Medicare	$1,292.90
Rate for Payer: Monida Allegiance	$1,754.65
Rate for Payer: Monida First Choice Health	$1,791.59
Rate for Payer: Monida Montana Health Co-op	$1,754.65
Rate for Payer: Monida PacificSource	$1,754.65

ER REMOVE FB UPPER ARM ELBOW AREA

Facility

$1,304.00

Service Code	HCPCS 24200
Hospital Charge Code	1024200
Hospital Revenue Code	450
Min. Negotiated Rate	$912.80
Max. Negotiated Rate	$1,304.00
Rate for Payer: Aetna Commercial	$1,238.80
Rate for Payer: Aetna Medicare	$1,173.60
Rate for Payer: BCBS MT CHIP	$1,173.60
Rate for Payer: BCBS MT Closed Plan Network	$1,238.80
Rate for Payer: BCBS MT HealthLink	$1,173.60
Rate for Payer: BCBS MT Medicare	$1,173.60
Rate for Payer: BCBS MT POS	$1,238.80
Rate for Payer: BCBS MT Traditional	$1,304.00
Rate for Payer: Cash Price	$1,173.60
Rate for Payer: Cigna Commercial	$1,238.80
Rate for Payer: Cigna Medicare	$1,173.60
Rate for Payer: Medicaid All Medicaid	$1,199.68
Rate for Payer: Medicare All Medicare	$912.80
Rate for Payer: Monida Allegiance	$1,238.80
Rate for Payer: Monida First Choice Health	$1,264.88
Rate for Payer: Monida Montana Health Co-op	$1,238.80
Rate for Payer: Monida PacificSource	$1,238.80

ER REMOVE FB UPPER ARM ELBOW AREA

Facility

$1,304.00

Service Code	HCPCS 24200
Hospital Charge Code	1024200
Hospital Revenue Code	450
Min. Negotiated Rate	$912.80
Max. Negotiated Rate	$1,304.00
Rate for Payer: Aetna Commercial	$1,238.80
Rate for Payer: Aetna Medicare	$1,173.60
Rate for Payer: BCBS MT CHIP	$1,173.60
Rate for Payer: BCBS MT Closed Plan Network	$1,238.80
Rate for Payer: BCBS MT HealthLink	$1,173.60
Rate for Payer: BCBS MT Medicare	$1,173.60
Rate for Payer: BCBS MT POS	$1,238.80
Rate for Payer: BCBS MT Traditional	$1,304.00
Rate for Payer: Cash Price	$1,173.60
Rate for Payer: Cigna Commercial	$1,238.80
Rate for Payer: Cigna Medicare	$1,173.60
Rate for Payer: Medicaid All Medicaid	$1,199.68
Rate for Payer: Medicare All Medicare	$912.80
Rate for Payer: Monida Allegiance	$1,238.80
Rate for Payer: Monida First Choice Health	$1,264.88
Rate for Payer: Monida Montana Health Co-op	$1,238.80
Rate for Payer: Monida PacificSource	$1,238.80

ER REMOVE FOREIGN BODY

Facility

$527.00

Service Code	HCPCS 10120
Hospital Charge Code	1010120
Hospital Revenue Code	450
Min. Negotiated Rate	$368.90
Max. Negotiated Rate	$527.00
Rate for Payer: Aetna Commercial	$500.65
Rate for Payer: Aetna Medicare	$474.30
Rate for Payer: BCBS MT CHIP	$474.30
Rate for Payer: BCBS MT Closed Plan Network	$500.65
Rate for Payer: BCBS MT HealthLink	$474.30
Rate for Payer: BCBS MT Medicare	$474.30
Rate for Payer: BCBS MT POS	$500.65
Rate for Payer: BCBS MT Traditional	$527.00
Rate for Payer: Cash Price	$474.30
Rate for Payer: Cigna Commercial	$500.65
Rate for Payer: Cigna Medicare	$474.30
Rate for Payer: Medicaid All Medicaid	$484.84
Rate for Payer: Medicare All Medicare	$368.90
Rate for Payer: Monida Allegiance	$500.65
Rate for Payer: Monida First Choice Health	$511.19
Rate for Payer: Monida Montana Health Co-op	$500.65
Rate for Payer: Monida PacificSource	$500.65

ER REMOVE FOREIGN BODY

Facility

$527.00

Service Code	HCPCS 10120
Hospital Charge Code	1010120
Hospital Revenue Code	450
Min. Negotiated Rate	$368.90
Max. Negotiated Rate	$527.00
Rate for Payer: Aetna Commercial	$500.65
Rate for Payer: Aetna Medicare	$474.30
Rate for Payer: BCBS MT CHIP	$474.30
Rate for Payer: BCBS MT Closed Plan Network	$500.65
Rate for Payer: BCBS MT HealthLink	$474.30
Rate for Payer: BCBS MT Medicare	$474.30
Rate for Payer: BCBS MT POS	$500.65
Rate for Payer: BCBS MT Traditional	$527.00
Rate for Payer: Cash Price	$474.30
Rate for Payer: Cigna Commercial	$500.65
Rate for Payer: Cigna Medicare	$474.30
Rate for Payer: Medicaid All Medicaid	$484.84
Rate for Payer: Medicare All Medicare	$368.90
Rate for Payer: Monida Allegiance	$500.65
Rate for Payer: Monida First Choice Health	$511.19
Rate for Payer: Monida Montana Health Co-op	$500.65
Rate for Payer: Monida PacificSource	$500.65

ER REMOVE FOREIGN BODY EYELID EXT CONJ

Facility

$235.00

Service Code	HCPCS 65205
Hospital Charge Code	1065205
Hospital Revenue Code	450
Min. Negotiated Rate	$164.50
Max. Negotiated Rate	$235.00
Rate for Payer: Aetna Commercial	$223.25
Rate for Payer: Aetna Medicare	$211.50
Rate for Payer: BCBS MT CHIP	$211.50
Rate for Payer: BCBS MT Closed Plan Network	$223.25
Rate for Payer: BCBS MT HealthLink	$211.50
Rate for Payer: BCBS MT Medicare	$211.50
Rate for Payer: BCBS MT POS	$223.25
Rate for Payer: BCBS MT Traditional	$235.00
Rate for Payer: Cash Price	$211.50
Rate for Payer: Cigna Commercial	$223.25
Rate for Payer: Cigna Medicare	$211.50
Rate for Payer: Medicaid All Medicaid	$216.20
Rate for Payer: Medicare All Medicare	$164.50
Rate for Payer: Monida Allegiance	$223.25
Rate for Payer: Monida First Choice Health	$227.95
Rate for Payer: Monida Montana Health Co-op	$223.25
Rate for Payer: Monida PacificSource	$223.25

ER REMOVE FOREIGN BODY EYELID EXT CONJ

Facility

$235.00

Service Code	HCPCS 65205
Hospital Charge Code	1065205
Hospital Revenue Code	450
Min. Negotiated Rate	$164.50
Max. Negotiated Rate	$235.00
Rate for Payer: Aetna Commercial	$223.25
Rate for Payer: Aetna Medicare	$211.50
Rate for Payer: BCBS MT CHIP	$211.50
Rate for Payer: BCBS MT Closed Plan Network	$223.25
Rate for Payer: BCBS MT HealthLink	$211.50
Rate for Payer: BCBS MT Medicare	$211.50
Rate for Payer: BCBS MT POS	$223.25
Rate for Payer: BCBS MT Traditional	$235.00
Rate for Payer: Cash Price	$211.50
Rate for Payer: Cigna Commercial	$223.25
Rate for Payer: Cigna Medicare	$211.50
Rate for Payer: Medicaid All Medicaid	$216.20
Rate for Payer: Medicare All Medicare	$164.50
Rate for Payer: Monida Allegiance	$223.25
Rate for Payer: Monida First Choice Health	$227.95
Rate for Payer: Monida Montana Health Co-op	$223.25
Rate for Payer: Monida PacificSource	$223.25

ER REMOVE NASAL FOREIGN BODY

Facility

$342.00

Service Code	HCPCS 30300
Hospital Charge Code	1030300
Hospital Revenue Code	450
Min. Negotiated Rate	$239.40
Max. Negotiated Rate	$342.00
Rate for Payer: Aetna Commercial	$324.90
Rate for Payer: Aetna Medicare	$307.80
Rate for Payer: BCBS MT CHIP	$307.80
Rate for Payer: BCBS MT Closed Plan Network	$324.90
Rate for Payer: BCBS MT HealthLink	$307.80
Rate for Payer: BCBS MT Medicare	$307.80
Rate for Payer: BCBS MT POS	$324.90
Rate for Payer: BCBS MT Traditional	$342.00
Rate for Payer: Cash Price	$307.80
Rate for Payer: Cigna Commercial	$324.90
Rate for Payer: Cigna Medicare	$307.80
Rate for Payer: Medicaid All Medicaid	$314.64
Rate for Payer: Medicare All Medicare	$239.40
Rate for Payer: Monida Allegiance	$324.90
Rate for Payer: Monida First Choice Health	$331.74
Rate for Payer: Monida Montana Health Co-op	$324.90
Rate for Payer: Monida PacificSource	$324.90

ER REMOVE NASAL FOREIGN BODY

Facility

$342.00

Service Code	HCPCS 30300
Hospital Charge Code	1030300
Hospital Revenue Code	450
Min. Negotiated Rate	$239.40
Max. Negotiated Rate	$342.00
Rate for Payer: Aetna Commercial	$324.90
Rate for Payer: Aetna Medicare	$307.80
Rate for Payer: BCBS MT CHIP	$307.80
Rate for Payer: BCBS MT Closed Plan Network	$324.90
Rate for Payer: BCBS MT HealthLink	$307.80
Rate for Payer: BCBS MT Medicare	$307.80
Rate for Payer: BCBS MT POS	$324.90
Rate for Payer: BCBS MT Traditional	$342.00
Rate for Payer: Cash Price	$307.80
Rate for Payer: Cigna Commercial	$324.90
Rate for Payer: Cigna Medicare	$307.80
Rate for Payer: Medicaid All Medicaid	$314.64
Rate for Payer: Medicare All Medicare	$239.40
Rate for Payer: Monida Allegiance	$324.90
Rate for Payer: Monida First Choice Health	$331.74
Rate for Payer: Monida Montana Health Co-op	$324.90
Rate for Payer: Monida PacificSource	$324.90

ER REMOV FOREIGN BODY EMBEDED EYLID EXT

Facility

$550.00

Service Code	HCPCS 67938
Hospital Charge Code	1067938
Hospital Revenue Code	450
Min. Negotiated Rate	$385.00
Max. Negotiated Rate	$550.00
Rate for Payer: Aetna Commercial	$522.50
Rate for Payer: Aetna Medicare	$495.00
Rate for Payer: BCBS MT CHIP	$495.00
Rate for Payer: BCBS MT Closed Plan Network	$522.50
Rate for Payer: BCBS MT HealthLink	$495.00
Rate for Payer: BCBS MT Medicare	$495.00
Rate for Payer: BCBS MT POS	$522.50
Rate for Payer: BCBS MT Traditional	$550.00
Rate for Payer: Cash Price	$495.00
Rate for Payer: Cigna Commercial	$522.50
Rate for Payer: Cigna Medicare	$495.00
Rate for Payer: Medicaid All Medicaid	$506.00
Rate for Payer: Medicare All Medicare	$385.00
Rate for Payer: Monida Allegiance	$522.50
Rate for Payer: Monida First Choice Health	$533.50
Rate for Payer: Monida Montana Health Co-op	$522.50
Rate for Payer: Monida PacificSource	$522.50

ER REMOV FOREIGN BODY EMBEDED EYLID EXT

Facility

$550.00

Service Code	HCPCS 67938
Hospital Charge Code	1067938
Hospital Revenue Code	450
Min. Negotiated Rate	$385.00
Max. Negotiated Rate	$550.00
Rate for Payer: Aetna Commercial	$522.50
Rate for Payer: Aetna Medicare	$495.00
Rate for Payer: BCBS MT CHIP	$495.00
Rate for Payer: BCBS MT Closed Plan Network	$522.50
Rate for Payer: BCBS MT HealthLink	$495.00
Rate for Payer: BCBS MT Medicare	$495.00
Rate for Payer: BCBS MT POS	$522.50
Rate for Payer: BCBS MT Traditional	$550.00
Rate for Payer: Cash Price	$495.00
Rate for Payer: Cigna Commercial	$522.50
Rate for Payer: Cigna Medicare	$495.00
Rate for Payer: Medicaid All Medicaid	$506.00
Rate for Payer: Medicare All Medicare	$385.00
Rate for Payer: Monida Allegiance	$522.50
Rate for Payer: Monida First Choice Health	$533.50
Rate for Payer: Monida Montana Health Co-op	$522.50
Rate for Payer: Monida PacificSource	$522.50

ER REPAIR COMPLEX 1.1-2.5 CM

Facility

$734.00

Service Code	HCPCS 13131
Hospital Charge Code	1013131
Hospital Revenue Code	450
Min. Negotiated Rate	$513.80
Max. Negotiated Rate	$734.00
Rate for Payer: Aetna Commercial	$697.30
Rate for Payer: Aetna Medicare	$660.60
Rate for Payer: BCBS MT CHIP	$660.60
Rate for Payer: BCBS MT Closed Plan Network	$697.30
Rate for Payer: BCBS MT HealthLink	$660.60
Rate for Payer: BCBS MT Medicare	$660.60
Rate for Payer: BCBS MT POS	$697.30
Rate for Payer: BCBS MT Traditional	$734.00
Rate for Payer: Cash Price	$660.60
Rate for Payer: Cigna Commercial	$697.30
Rate for Payer: Cigna Medicare	$660.60
Rate for Payer: Medicaid All Medicaid	$675.28
Rate for Payer: Medicare All Medicare	$513.80
Rate for Payer: Monida Allegiance	$697.30
Rate for Payer: Monida First Choice Health	$711.98
Rate for Payer: Monida Montana Health Co-op	$697.30
Rate for Payer: Monida PacificSource	$697.30

ER REPAIR COMPLEX 1.1-2.5 CM

Facility

$734.00

Service Code	HCPCS 13131
Hospital Charge Code	1013131
Hospital Revenue Code	450
Min. Negotiated Rate	$513.80
Max. Negotiated Rate	$734.00
Rate for Payer: Aetna Commercial	$697.30
Rate for Payer: Aetna Medicare	$660.60
Rate for Payer: BCBS MT CHIP	$660.60
Rate for Payer: BCBS MT Closed Plan Network	$697.30
Rate for Payer: BCBS MT HealthLink	$660.60
Rate for Payer: BCBS MT Medicare	$660.60
Rate for Payer: BCBS MT POS	$697.30
Rate for Payer: BCBS MT Traditional	$734.00
Rate for Payer: Cash Price	$660.60
Rate for Payer: Cigna Commercial	$697.30
Rate for Payer: Cigna Medicare	$660.60
Rate for Payer: Medicaid All Medicaid	$675.28
Rate for Payer: Medicare All Medicare	$513.80
Rate for Payer: Monida Allegiance	$697.30
Rate for Payer: Monida First Choice Health	$711.98
Rate for Payer: Monida Montana Health Co-op	$697.30
Rate for Payer: Monida PacificSource	$697.30

Know your out-of-pocket cost for care.

All Charges