Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

D/C SUGAMMADEX [500 MG/5 ML]

Facility

$706.00

Service Code	HCPCS J3490
Hospital Charge Code	3000436
Hospital Revenue Code	259
Min. Negotiated Rate	$494.20
Max. Negotiated Rate	$706.00
Rate for Payer: Aetna Commercial	$670.70
Rate for Payer: Aetna Medicare	$635.40
Rate for Payer: BCBS MT CHIP	$635.40
Rate for Payer: BCBS MT Closed Plan Network	$670.70
Rate for Payer: BCBS MT HealthLink	$635.40
Rate for Payer: BCBS MT Medicare	$635.40
Rate for Payer: BCBS MT POS	$670.70
Rate for Payer: BCBS MT Traditional	$706.00
Rate for Payer: Cash Price	$635.40
Rate for Payer: Cigna Commercial	$670.70
Rate for Payer: Cigna Medicare	$635.40
Rate for Payer: Medicaid All Medicaid	$649.52
Rate for Payer: Medicare All Medicare	$494.20
Rate for Payer: Monida Allegiance	$670.70
Rate for Payer: Monida First Choice Health	$684.82
Rate for Payer: Monida Montana Health Co-op	$670.70
Rate for Payer: Monida PacificSource	$670.70

D/C SUGAMMADEX [500 MG/5 ML]

Facility

$706.00

Service Code	HCPCS J3490
Hospital Charge Code	3000436
Hospital Revenue Code	259
Min. Negotiated Rate	$494.20
Max. Negotiated Rate	$706.00
Rate for Payer: Aetna Commercial	$670.70
Rate for Payer: Aetna Medicare	$635.40
Rate for Payer: BCBS MT CHIP	$635.40
Rate for Payer: BCBS MT Closed Plan Network	$670.70
Rate for Payer: BCBS MT HealthLink	$635.40
Rate for Payer: BCBS MT Medicare	$635.40
Rate for Payer: BCBS MT POS	$670.70
Rate for Payer: BCBS MT Traditional	$706.00
Rate for Payer: Cash Price	$635.40
Rate for Payer: Cigna Commercial	$670.70
Rate for Payer: Cigna Medicare	$635.40
Rate for Payer: Medicaid All Medicaid	$649.52
Rate for Payer: Medicare All Medicare	$494.20
Rate for Payer: Monida Allegiance	$670.70
Rate for Payer: Monida First Choice Health	$684.82
Rate for Payer: Monida Montana Health Co-op	$670.70
Rate for Payer: Monida PacificSource	$670.70

D/C VANCOMYCIN CAPS [250MG]

Facility

$194.00

Service Code	HCPCS J3490
Hospital Charge Code	3000473
Hospital Revenue Code	250
Min. Negotiated Rate	$135.80
Max. Negotiated Rate	$194.00
Rate for Payer: Aetna Commercial	$184.30
Rate for Payer: Aetna Medicare	$174.60
Rate for Payer: BCBS MT CHIP	$174.60
Rate for Payer: BCBS MT Closed Plan Network	$184.30
Rate for Payer: BCBS MT HealthLink	$174.60
Rate for Payer: BCBS MT Medicare	$174.60
Rate for Payer: BCBS MT POS	$184.30
Rate for Payer: BCBS MT Traditional	$194.00
Rate for Payer: Cash Price	$174.60
Rate for Payer: Cigna Commercial	$184.30
Rate for Payer: Cigna Medicare	$174.60
Rate for Payer: Medicaid All Medicaid	$178.48
Rate for Payer: Medicare All Medicare	$135.80
Rate for Payer: Monida Allegiance	$184.30
Rate for Payer: Monida First Choice Health	$188.18
Rate for Payer: Monida Montana Health Co-op	$184.30
Rate for Payer: Monida PacificSource	$184.30

D/C VANCOMYCIN CAPS [250MG]

Facility

$194.00

Service Code	HCPCS J3490
Hospital Charge Code	3000473
Hospital Revenue Code	250
Min. Negotiated Rate	$135.80
Max. Negotiated Rate	$194.00
Rate for Payer: Aetna Commercial	$184.30
Rate for Payer: Aetna Medicare	$174.60
Rate for Payer: BCBS MT CHIP	$174.60
Rate for Payer: BCBS MT Closed Plan Network	$184.30
Rate for Payer: BCBS MT HealthLink	$174.60
Rate for Payer: BCBS MT Medicare	$174.60
Rate for Payer: BCBS MT POS	$184.30
Rate for Payer: BCBS MT Traditional	$194.00
Rate for Payer: Cash Price	$174.60
Rate for Payer: Cigna Commercial	$184.30
Rate for Payer: Cigna Medicare	$174.60
Rate for Payer: Medicaid All Medicaid	$178.48
Rate for Payer: Medicare All Medicare	$135.80
Rate for Payer: Monida Allegiance	$184.30
Rate for Payer: Monida First Choice Health	$188.18
Rate for Payer: Monida Montana Health Co-op	$184.30
Rate for Payer: Monida PacificSource	$184.30

D/C - VITAMIN C 500MG (001805)

Facility

$53.00

Service Code	CPT 82180
Hospital Charge Code	4082180
Hospital Revenue Code	300
Min. Negotiated Rate	$37.10
Max. Negotiated Rate	$53.00
Rate for Payer: Aetna Commercial	$50.35
Rate for Payer: Aetna Medicare	$47.70
Rate for Payer: BCBS MT CHIP	$47.70
Rate for Payer: BCBS MT Closed Plan Network	$50.35
Rate for Payer: BCBS MT HealthLink	$47.70
Rate for Payer: BCBS MT Medicare	$47.70
Rate for Payer: BCBS MT POS	$50.35
Rate for Payer: BCBS MT Traditional	$53.00
Rate for Payer: Cash Price	$47.70
Rate for Payer: Cigna Commercial	$50.35
Rate for Payer: Cigna Medicare	$47.70
Rate for Payer: Medicaid All Medicaid	$48.76
Rate for Payer: Medicare All Medicare	$37.10
Rate for Payer: Monida Allegiance	$50.35
Rate for Payer: Monida First Choice Health	$51.41
Rate for Payer: Monida Montana Health Co-op	$50.35
Rate for Payer: Monida PacificSource	$50.35

D/C - VITAMIN C 500MG (001805)

Facility

$53.00

Service Code	CPT 82180
Hospital Charge Code	4082180
Hospital Revenue Code	300
Min. Negotiated Rate	$37.10
Max. Negotiated Rate	$53.00
Rate for Payer: Aetna Commercial	$50.35
Rate for Payer: Aetna Medicare	$47.70
Rate for Payer: BCBS MT CHIP	$47.70
Rate for Payer: BCBS MT Closed Plan Network	$50.35
Rate for Payer: BCBS MT HealthLink	$47.70
Rate for Payer: BCBS MT Medicare	$47.70
Rate for Payer: BCBS MT POS	$50.35
Rate for Payer: BCBS MT Traditional	$53.00
Rate for Payer: Cash Price	$47.70
Rate for Payer: Cigna Commercial	$50.35
Rate for Payer: Cigna Medicare	$47.70
Rate for Payer: Medicaid All Medicaid	$48.76
Rate for Payer: Medicare All Medicare	$37.10
Rate for Payer: Monida Allegiance	$50.35
Rate for Payer: Monida First Choice Health	$51.41
Rate for Payer: Monida Montana Health Co-op	$50.35
Rate for Payer: Monida PacificSource	$50.35

D/C ZINC OXIDE & DIMETHICONE CREAM 113GM

Facility

$13.00

Service Code	HCPCS J3490
Hospital Charge Code	3000487
Hospital Revenue Code	259
Min. Negotiated Rate	$9.10
Max. Negotiated Rate	$13.00
Rate for Payer: Aetna Commercial	$12.35
Rate for Payer: Aetna Medicare	$11.70
Rate for Payer: BCBS MT CHIP	$11.70
Rate for Payer: BCBS MT Closed Plan Network	$12.35
Rate for Payer: BCBS MT HealthLink	$11.70
Rate for Payer: BCBS MT Medicare	$11.70
Rate for Payer: BCBS MT POS	$12.35
Rate for Payer: BCBS MT Traditional	$13.00
Rate for Payer: Cash Price	$11.70
Rate for Payer: Cigna Commercial	$12.35
Rate for Payer: Cigna Medicare	$11.70
Rate for Payer: Medicaid All Medicaid	$11.96
Rate for Payer: Medicare All Medicare	$9.10
Rate for Payer: Monida Allegiance	$12.35
Rate for Payer: Monida First Choice Health	$12.61
Rate for Payer: Monida Montana Health Co-op	$12.35
Rate for Payer: Monida PacificSource	$12.35

D/C ZINC OXIDE & DIMETHICONE CREAM 113GM

Facility

$13.00

Service Code	HCPCS J3490
Hospital Charge Code	3000487
Hospital Revenue Code	259
Min. Negotiated Rate	$9.10
Max. Negotiated Rate	$13.00
Rate for Payer: Aetna Commercial	$12.35
Rate for Payer: Aetna Medicare	$11.70
Rate for Payer: BCBS MT CHIP	$11.70
Rate for Payer: BCBS MT Closed Plan Network	$12.35
Rate for Payer: BCBS MT HealthLink	$11.70
Rate for Payer: BCBS MT Medicare	$11.70
Rate for Payer: BCBS MT POS	$12.35
Rate for Payer: BCBS MT Traditional	$13.00
Rate for Payer: Cash Price	$11.70
Rate for Payer: Cigna Commercial	$12.35
Rate for Payer: Cigna Medicare	$11.70
Rate for Payer: Medicaid All Medicaid	$11.96
Rate for Payer: Medicare All Medicare	$9.10
Rate for Payer: Monida Allegiance	$12.35
Rate for Payer: Monida First Choice Health	$12.61
Rate for Payer: Monida Montana Health Co-op	$12.35
Rate for Payer: Monida PacificSource	$12.35

D-DIMER QUANTITIVE

Facility

$174.00

Service Code	CPT 85379
Hospital Charge Code	4085379
Hospital Revenue Code	305
Min. Negotiated Rate	$121.80
Max. Negotiated Rate	$174.00
Rate for Payer: Aetna Commercial	$165.30
Rate for Payer: Aetna Medicare	$156.60
Rate for Payer: BCBS MT CHIP	$156.60
Rate for Payer: BCBS MT Closed Plan Network	$165.30
Rate for Payer: BCBS MT HealthLink	$156.60
Rate for Payer: BCBS MT Medicare	$156.60
Rate for Payer: BCBS MT POS	$165.30
Rate for Payer: BCBS MT Traditional	$174.00
Rate for Payer: Cash Price	$156.60
Rate for Payer: Cigna Commercial	$165.30
Rate for Payer: Cigna Medicare	$156.60
Rate for Payer: Medicaid All Medicaid	$160.08
Rate for Payer: Medicare All Medicare	$121.80
Rate for Payer: Monida Allegiance	$165.30
Rate for Payer: Monida First Choice Health	$168.78
Rate for Payer: Monida Montana Health Co-op	$165.30
Rate for Payer: Monida PacificSource	$165.30

D-DIMER QUANTITIVE

Facility

$174.00

Service Code	CPT 85379
Hospital Charge Code	4085379
Hospital Revenue Code	305
Min. Negotiated Rate	$121.80
Max. Negotiated Rate	$174.00
Rate for Payer: Aetna Commercial	$165.30
Rate for Payer: Aetna Medicare	$156.60
Rate for Payer: BCBS MT CHIP	$156.60
Rate for Payer: BCBS MT Closed Plan Network	$165.30
Rate for Payer: BCBS MT HealthLink	$156.60
Rate for Payer: BCBS MT Medicare	$156.60
Rate for Payer: BCBS MT POS	$165.30
Rate for Payer: BCBS MT Traditional	$174.00
Rate for Payer: Cash Price	$156.60
Rate for Payer: Cigna Commercial	$165.30
Rate for Payer: Cigna Medicare	$156.60
Rate for Payer: Medicaid All Medicaid	$160.08
Rate for Payer: Medicare All Medicare	$121.80
Rate for Payer: Monida Allegiance	$165.30
Rate for Payer: Monida First Choice Health	$168.78
Rate for Payer: Monida Montana Health Co-op	$165.30
Rate for Payer: Monida PacificSource	$165.30

DEBRIDE/DRESS BURN >5% (16020)

Facility

$387.00

Service Code	CPT 16020
Hospital Charge Code	8016020
Hospital Revenue Code	521
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

DEBRIDE/DRESS BURN >5% (16020)

Facility

$387.00

Service Code	CPT 16020
Hospital Charge Code	8016020
Hospital Revenue Code	521
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

DEBRIDEMENT 20CM OR LESS (97597)

Facility

$524.00

Service Code	CPT 97597
Hospital Charge Code	8097597
Hospital Revenue Code	521
Min. Negotiated Rate	$366.80
Max. Negotiated Rate	$524.00
Rate for Payer: Aetna Commercial	$497.80
Rate for Payer: Aetna Medicare	$471.60
Rate for Payer: BCBS MT CHIP	$471.60
Rate for Payer: BCBS MT Closed Plan Network	$497.80
Rate for Payer: BCBS MT HealthLink	$471.60
Rate for Payer: BCBS MT Medicare	$471.60
Rate for Payer: BCBS MT POS	$497.80
Rate for Payer: BCBS MT Traditional	$524.00
Rate for Payer: Cash Price	$471.60
Rate for Payer: Cigna Commercial	$497.80
Rate for Payer: Cigna Medicare	$471.60
Rate for Payer: Medicaid All Medicaid	$482.08
Rate for Payer: Medicare All Medicare	$366.80
Rate for Payer: Monida Allegiance	$497.80
Rate for Payer: Monida First Choice Health	$508.28
Rate for Payer: Monida Montana Health Co-op	$497.80
Rate for Payer: Monida PacificSource	$497.80

DEBRIDEMENT 20CM OR LESS (97597)

Facility

$524.00

Service Code	CPT 97597
Hospital Charge Code	8097597
Hospital Revenue Code	521
Min. Negotiated Rate	$366.80
Max. Negotiated Rate	$524.00
Rate for Payer: Aetna Commercial	$497.80
Rate for Payer: Aetna Medicare	$471.60
Rate for Payer: BCBS MT CHIP	$471.60
Rate for Payer: BCBS MT Closed Plan Network	$497.80
Rate for Payer: BCBS MT HealthLink	$471.60
Rate for Payer: BCBS MT Medicare	$471.60
Rate for Payer: BCBS MT POS	$497.80
Rate for Payer: BCBS MT Traditional	$524.00
Rate for Payer: Cash Price	$471.60
Rate for Payer: Cigna Commercial	$497.80
Rate for Payer: Cigna Medicare	$471.60
Rate for Payer: Medicaid All Medicaid	$482.08
Rate for Payer: Medicare All Medicare	$366.80
Rate for Payer: Monida Allegiance	$497.80
Rate for Payer: Monida First Choice Health	$508.28
Rate for Payer: Monida Montana Health Co-op	$497.80
Rate for Payer: Monida PacificSource	$497.80

DEBRIDEMENT 20SQCM OR LESS-SWG BD 97597

Facility

$343.00

Service Code	CPT 97597
Hospital Charge Code	597599
Hospital Revenue Code	761
Min. Negotiated Rate	$240.10
Max. Negotiated Rate	$343.00
Rate for Payer: Aetna Commercial	$325.85
Rate for Payer: Aetna Medicare	$308.70
Rate for Payer: BCBS MT CHIP	$308.70
Rate for Payer: BCBS MT Closed Plan Network	$325.85
Rate for Payer: BCBS MT HealthLink	$308.70
Rate for Payer: BCBS MT Medicare	$308.70
Rate for Payer: BCBS MT POS	$325.85
Rate for Payer: BCBS MT Traditional	$343.00
Rate for Payer: Cash Price	$308.70
Rate for Payer: Cigna Commercial	$325.85
Rate for Payer: Cigna Medicare	$308.70
Rate for Payer: Medicaid All Medicaid	$315.56
Rate for Payer: Medicare All Medicare	$240.10
Rate for Payer: Monida Allegiance	$325.85
Rate for Payer: Monida First Choice Health	$332.71
Rate for Payer: Monida Montana Health Co-op	$325.85
Rate for Payer: Monida PacificSource	$325.85

DEBRIDEMENT 20SQCM OR LESS-SWG BD 97597

Facility

$343.00

Service Code	CPT 97597
Hospital Charge Code	597599
Hospital Revenue Code	761
Min. Negotiated Rate	$240.10
Max. Negotiated Rate	$343.00
Rate for Payer: Aetna Commercial	$325.85
Rate for Payer: Aetna Medicare	$308.70
Rate for Payer: BCBS MT CHIP	$308.70
Rate for Payer: BCBS MT Closed Plan Network	$325.85
Rate for Payer: BCBS MT HealthLink	$308.70
Rate for Payer: BCBS MT Medicare	$308.70
Rate for Payer: BCBS MT POS	$325.85
Rate for Payer: BCBS MT Traditional	$343.00
Rate for Payer: Cash Price	$308.70
Rate for Payer: Cigna Commercial	$325.85
Rate for Payer: Cigna Medicare	$308.70
Rate for Payer: Medicaid All Medicaid	$315.56
Rate for Payer: Medicare All Medicare	$240.10
Rate for Payer: Monida Allegiance	$325.85
Rate for Payer: Monida First Choice Health	$332.71
Rate for Payer: Monida Montana Health Co-op	$325.85
Rate for Payer: Monida PacificSource	$325.85

DEBRIDEMENT 20SQCM OR LESS-TRT RM 97597

Facility

$524.00

Service Code	CPT 97597
Hospital Charge Code	597597
Hospital Revenue Code	761
Min. Negotiated Rate	$366.80
Max. Negotiated Rate	$524.00
Rate for Payer: Aetna Commercial	$497.80
Rate for Payer: Aetna Medicare	$471.60
Rate for Payer: BCBS MT CHIP	$471.60
Rate for Payer: BCBS MT Closed Plan Network	$497.80
Rate for Payer: BCBS MT HealthLink	$471.60
Rate for Payer: BCBS MT Medicare	$471.60
Rate for Payer: BCBS MT POS	$497.80
Rate for Payer: BCBS MT Traditional	$524.00
Rate for Payer: Cash Price	$471.60
Rate for Payer: Cigna Commercial	$497.80
Rate for Payer: Cigna Medicare	$471.60
Rate for Payer: Medicaid All Medicaid	$482.08
Rate for Payer: Medicare All Medicare	$366.80
Rate for Payer: Monida Allegiance	$497.80
Rate for Payer: Monida First Choice Health	$508.28
Rate for Payer: Monida Montana Health Co-op	$497.80
Rate for Payer: Monida PacificSource	$497.80

DEBRIDEMENT 20SQCM OR LESS-TRT RM 97597

Facility

$524.00

Service Code	CPT 97597
Hospital Charge Code	597597
Hospital Revenue Code	761
Min. Negotiated Rate	$366.80
Max. Negotiated Rate	$524.00
Rate for Payer: Aetna Commercial	$497.80
Rate for Payer: Aetna Medicare	$471.60
Rate for Payer: BCBS MT CHIP	$471.60
Rate for Payer: BCBS MT Closed Plan Network	$497.80
Rate for Payer: BCBS MT HealthLink	$471.60
Rate for Payer: BCBS MT Medicare	$471.60
Rate for Payer: BCBS MT POS	$497.80
Rate for Payer: BCBS MT Traditional	$524.00
Rate for Payer: Cash Price	$471.60
Rate for Payer: Cigna Commercial	$497.80
Rate for Payer: Cigna Medicare	$471.60
Rate for Payer: Medicaid All Medicaid	$482.08
Rate for Payer: Medicare All Medicare	$366.80
Rate for Payer: Monida Allegiance	$497.80
Rate for Payer: Monida First Choice Health	$508.28
Rate for Payer: Monida Montana Health Co-op	$497.80
Rate for Payer: Monida PacificSource	$497.80

DEBRIDEMENT EA ADD 20SQCM-SWG BED 97598

Facility

$406.00

Service Code	CPT 97598
Hospital Charge Code	597600
Hospital Revenue Code	761
Min. Negotiated Rate	$284.20
Max. Negotiated Rate	$406.00
Rate for Payer: Aetna Commercial	$385.70
Rate for Payer: Aetna Medicare	$365.40
Rate for Payer: BCBS MT CHIP	$365.40
Rate for Payer: BCBS MT Closed Plan Network	$385.70
Rate for Payer: BCBS MT HealthLink	$365.40
Rate for Payer: BCBS MT Medicare	$365.40
Rate for Payer: BCBS MT POS	$385.70
Rate for Payer: BCBS MT Traditional	$406.00
Rate for Payer: Cash Price	$365.40
Rate for Payer: Cigna Commercial	$385.70
Rate for Payer: Cigna Medicare	$365.40
Rate for Payer: Medicaid All Medicaid	$373.52
Rate for Payer: Medicare All Medicare	$284.20
Rate for Payer: Monida Allegiance	$385.70
Rate for Payer: Monida First Choice Health	$393.82
Rate for Payer: Monida Montana Health Co-op	$385.70
Rate for Payer: Monida PacificSource	$385.70

DEBRIDEMENT EA ADD 20SQCM-SWG BED 97598

Facility

$406.00

Service Code	CPT 97598
Hospital Charge Code	597600
Hospital Revenue Code	761
Min. Negotiated Rate	$284.20
Max. Negotiated Rate	$406.00
Rate for Payer: Aetna Commercial	$385.70
Rate for Payer: Aetna Medicare	$365.40
Rate for Payer: BCBS MT CHIP	$365.40
Rate for Payer: BCBS MT Closed Plan Network	$385.70
Rate for Payer: BCBS MT HealthLink	$365.40
Rate for Payer: BCBS MT Medicare	$365.40
Rate for Payer: BCBS MT POS	$385.70
Rate for Payer: BCBS MT Traditional	$406.00
Rate for Payer: Cash Price	$365.40
Rate for Payer: Cigna Commercial	$385.70
Rate for Payer: Cigna Medicare	$365.40
Rate for Payer: Medicaid All Medicaid	$373.52
Rate for Payer: Medicare All Medicare	$284.20
Rate for Payer: Monida Allegiance	$385.70
Rate for Payer: Monida First Choice Health	$393.82
Rate for Payer: Monida Montana Health Co-op	$385.70
Rate for Payer: Monida PacificSource	$385.70

DEBRIDEMENT EA ADD 20SQCM- TRT RM 97598

Facility

$406.00

Service Code	CPT 97598
Hospital Charge Code	597598
Hospital Revenue Code	761
Min. Negotiated Rate	$284.20
Max. Negotiated Rate	$406.00
Rate for Payer: Aetna Commercial	$385.70
Rate for Payer: Aetna Medicare	$365.40
Rate for Payer: BCBS MT CHIP	$365.40
Rate for Payer: BCBS MT Closed Plan Network	$385.70
Rate for Payer: BCBS MT HealthLink	$365.40
Rate for Payer: BCBS MT Medicare	$365.40
Rate for Payer: BCBS MT POS	$385.70
Rate for Payer: BCBS MT Traditional	$406.00
Rate for Payer: Cash Price	$365.40
Rate for Payer: Cigna Commercial	$385.70
Rate for Payer: Cigna Medicare	$365.40
Rate for Payer: Medicaid All Medicaid	$373.52
Rate for Payer: Medicare All Medicare	$284.20
Rate for Payer: Monida Allegiance	$385.70
Rate for Payer: Monida First Choice Health	$393.82
Rate for Payer: Monida Montana Health Co-op	$385.70
Rate for Payer: Monida PacificSource	$385.70

DEBRIDEMENT EA ADD 20SQCM- TRT RM 97598

Facility

$406.00

Service Code	CPT 97598
Hospital Charge Code	597598
Hospital Revenue Code	761
Min. Negotiated Rate	$284.20
Max. Negotiated Rate	$406.00
Rate for Payer: Aetna Commercial	$385.70
Rate for Payer: Aetna Medicare	$365.40
Rate for Payer: BCBS MT CHIP	$365.40
Rate for Payer: BCBS MT Closed Plan Network	$385.70
Rate for Payer: BCBS MT HealthLink	$365.40
Rate for Payer: BCBS MT Medicare	$365.40
Rate for Payer: BCBS MT POS	$385.70
Rate for Payer: BCBS MT Traditional	$406.00
Rate for Payer: Cash Price	$365.40
Rate for Payer: Cigna Commercial	$385.70
Rate for Payer: Cigna Medicare	$365.40
Rate for Payer: Medicaid All Medicaid	$373.52
Rate for Payer: Medicare All Medicare	$284.20
Rate for Payer: Monida Allegiance	$385.70
Rate for Payer: Monida First Choice Health	$393.82
Rate for Payer: Monida Montana Health Co-op	$385.70
Rate for Payer: Monida PacificSource	$385.70

DEBRIDEMENT NAIL(S) ONE TO FIVE (11720)

Facility

$182.00

Service Code	CPT 11720
Hospital Charge Code	8011720
Hospital Revenue Code	521
Min. Negotiated Rate	$127.40
Max. Negotiated Rate	$182.00
Rate for Payer: Aetna Commercial	$172.90
Rate for Payer: Aetna Medicare	$163.80
Rate for Payer: BCBS MT CHIP	$163.80
Rate for Payer: BCBS MT Closed Plan Network	$172.90
Rate for Payer: BCBS MT HealthLink	$163.80
Rate for Payer: BCBS MT Medicare	$163.80
Rate for Payer: BCBS MT POS	$172.90
Rate for Payer: BCBS MT Traditional	$182.00
Rate for Payer: Cash Price	$163.80
Rate for Payer: Cigna Commercial	$172.90
Rate for Payer: Cigna Medicare	$163.80
Rate for Payer: Medicaid All Medicaid	$167.44
Rate for Payer: Medicare All Medicare	$127.40
Rate for Payer: Monida Allegiance	$172.90
Rate for Payer: Monida First Choice Health	$176.54
Rate for Payer: Monida Montana Health Co-op	$172.90
Rate for Payer: Monida PacificSource	$172.90

DEBRIDEMENT NAIL(S) ONE TO FIVE (11720)

Facility

$182.00

Service Code	CPT 11720
Hospital Charge Code	8011720
Hospital Revenue Code	521
Min. Negotiated Rate	$127.40
Max. Negotiated Rate	$182.00
Rate for Payer: Aetna Commercial	$172.90
Rate for Payer: Aetna Medicare	$163.80
Rate for Payer: BCBS MT CHIP	$163.80
Rate for Payer: BCBS MT Closed Plan Network	$172.90
Rate for Payer: BCBS MT HealthLink	$163.80
Rate for Payer: BCBS MT Medicare	$163.80
Rate for Payer: BCBS MT POS	$172.90
Rate for Payer: BCBS MT Traditional	$182.00
Rate for Payer: Cash Price	$163.80
Rate for Payer: Cigna Commercial	$172.90
Rate for Payer: Cigna Medicare	$163.80
Rate for Payer: Medicaid All Medicaid	$167.44
Rate for Payer: Medicare All Medicare	$127.40
Rate for Payer: Monida Allegiance	$172.90
Rate for Payer: Monida First Choice Health	$176.54
Rate for Payer: Monida Montana Health Co-op	$172.90
Rate for Payer: Monida PacificSource	$172.90

DEBRIDEMENT NON-SELECTIVE W/O ANES 97602

Facility

$364.00

Service Code	CPT 97602
Hospital Charge Code	597602
Hospital Revenue Code	761
Min. Negotiated Rate	$254.80
Max. Negotiated Rate	$364.00
Rate for Payer: Aetna Commercial	$345.80
Rate for Payer: Aetna Medicare	$327.60
Rate for Payer: BCBS MT CHIP	$327.60
Rate for Payer: BCBS MT Closed Plan Network	$345.80
Rate for Payer: BCBS MT HealthLink	$327.60
Rate for Payer: BCBS MT Medicare	$327.60
Rate for Payer: BCBS MT POS	$345.80
Rate for Payer: BCBS MT Traditional	$364.00
Rate for Payer: Cash Price	$327.60
Rate for Payer: Cigna Commercial	$345.80
Rate for Payer: Cigna Medicare	$327.60
Rate for Payer: Medicaid All Medicaid	$334.88
Rate for Payer: Medicare All Medicare	$254.80
Rate for Payer: Monida Allegiance	$345.80
Rate for Payer: Monida First Choice Health	$353.08
Rate for Payer: Monida Montana Health Co-op	$345.80
Rate for Payer: Monida PacificSource	$345.80

Know your out-of-pocket cost for care.

All Charges