Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

ER REPAIR SIMPLE S/N/A/HF 20.1-30CM

Facility

$423.00

Service Code	HCPCS 12006
Hospital Charge Code	1012006
Hospital Revenue Code	450
Min. Negotiated Rate	$296.10
Max. Negotiated Rate	$423.00
Rate for Payer: Aetna Commercial	$401.85
Rate for Payer: Aetna Medicare	$380.70
Rate for Payer: BCBS MT CHIP	$380.70
Rate for Payer: BCBS MT Closed Plan Network	$401.85
Rate for Payer: BCBS MT HealthLink	$380.70
Rate for Payer: BCBS MT Medicare	$380.70
Rate for Payer: BCBS MT POS	$401.85
Rate for Payer: BCBS MT Traditional	$423.00
Rate for Payer: Cash Price	$380.70
Rate for Payer: Cigna Commercial	$401.85
Rate for Payer: Cigna Medicare	$380.70
Rate for Payer: Medicaid All Medicaid	$389.16
Rate for Payer: Medicare All Medicare	$296.10
Rate for Payer: Monida Allegiance	$401.85
Rate for Payer: Monida First Choice Health	$410.31
Rate for Payer: Monida Montana Health Co-op	$401.85
Rate for Payer: Monida PacificSource	$401.85

ER REPAIR SIMPLE S/N/A/HF 20.1-30CM

Facility

$423.00

Service Code	HCPCS 12006
Hospital Charge Code	1012006
Hospital Revenue Code	450
Min. Negotiated Rate	$296.10
Max. Negotiated Rate	$423.00
Rate for Payer: Aetna Commercial	$401.85
Rate for Payer: Aetna Medicare	$380.70
Rate for Payer: BCBS MT CHIP	$380.70
Rate for Payer: BCBS MT Closed Plan Network	$401.85
Rate for Payer: BCBS MT HealthLink	$380.70
Rate for Payer: BCBS MT Medicare	$380.70
Rate for Payer: BCBS MT POS	$401.85
Rate for Payer: BCBS MT Traditional	$423.00
Rate for Payer: Cash Price	$380.70
Rate for Payer: Cigna Commercial	$401.85
Rate for Payer: Cigna Medicare	$380.70
Rate for Payer: Medicaid All Medicaid	$389.16
Rate for Payer: Medicare All Medicare	$296.10
Rate for Payer: Monida Allegiance	$401.85
Rate for Payer: Monida First Choice Health	$410.31
Rate for Payer: Monida Montana Health Co-op	$401.85
Rate for Payer: Monida PacificSource	$401.85

ER REPAIR SIM,S/N/T/HF 12.6 TO 20CM

Facility

$400.00

Service Code	HCPCS 12005
Hospital Charge Code	1012005
Hospital Revenue Code	450
Min. Negotiated Rate	$280.00
Max. Negotiated Rate	$400.00
Rate for Payer: Aetna Commercial	$380.00
Rate for Payer: Aetna Medicare	$360.00
Rate for Payer: BCBS MT CHIP	$360.00
Rate for Payer: BCBS MT Closed Plan Network	$380.00
Rate for Payer: BCBS MT HealthLink	$360.00
Rate for Payer: BCBS MT Medicare	$360.00
Rate for Payer: BCBS MT POS	$380.00
Rate for Payer: BCBS MT Traditional	$400.00
Rate for Payer: Cash Price	$360.00
Rate for Payer: Cigna Commercial	$380.00
Rate for Payer: Cigna Medicare	$360.00
Rate for Payer: Medicaid All Medicaid	$368.00
Rate for Payer: Medicare All Medicare	$280.00
Rate for Payer: Monida Allegiance	$380.00
Rate for Payer: Monida First Choice Health	$388.00
Rate for Payer: Monida Montana Health Co-op	$380.00
Rate for Payer: Monida PacificSource	$380.00

ER REPAIR SIM,S/N/T/HF 12.6 TO 20CM

Facility

$400.00

Service Code	HCPCS 12005
Hospital Charge Code	1012005
Hospital Revenue Code	450
Min. Negotiated Rate	$280.00
Max. Negotiated Rate	$400.00
Rate for Payer: Aetna Commercial	$380.00
Rate for Payer: Aetna Medicare	$360.00
Rate for Payer: BCBS MT CHIP	$360.00
Rate for Payer: BCBS MT Closed Plan Network	$380.00
Rate for Payer: BCBS MT HealthLink	$360.00
Rate for Payer: BCBS MT Medicare	$360.00
Rate for Payer: BCBS MT POS	$380.00
Rate for Payer: BCBS MT Traditional	$400.00
Rate for Payer: Cash Price	$360.00
Rate for Payer: Cigna Commercial	$380.00
Rate for Payer: Cigna Medicare	$360.00
Rate for Payer: Medicaid All Medicaid	$368.00
Rate for Payer: Medicare All Medicare	$280.00
Rate for Payer: Monida Allegiance	$380.00
Rate for Payer: Monida First Choice Health	$388.00
Rate for Payer: Monida Montana Health Co-op	$380.00
Rate for Payer: Monida PacificSource	$380.00

ER ROOM/OPO EVALUATION FROM CLINIC

Facility

$94.00

Service Code	HCPCS 99211
Hospital Charge Code	1010111
Hospital Revenue Code	760
Min. Negotiated Rate	$65.80
Max. Negotiated Rate	$94.00
Rate for Payer: Aetna Commercial	$89.30
Rate for Payer: Aetna Medicare	$84.60
Rate for Payer: BCBS MT CHIP	$84.60
Rate for Payer: BCBS MT Closed Plan Network	$89.30
Rate for Payer: BCBS MT HealthLink	$84.60
Rate for Payer: BCBS MT Medicare	$84.60
Rate for Payer: BCBS MT POS	$89.30
Rate for Payer: BCBS MT Traditional	$94.00
Rate for Payer: Cash Price	$84.60
Rate for Payer: Cigna Commercial	$89.30
Rate for Payer: Cigna Medicare	$84.60
Rate for Payer: Medicaid All Medicaid	$86.48
Rate for Payer: Medicare All Medicare	$65.80
Rate for Payer: Monida Allegiance	$89.30
Rate for Payer: Monida First Choice Health	$91.18
Rate for Payer: Monida Montana Health Co-op	$89.30
Rate for Payer: Monida PacificSource	$89.30

ER ROOM/OPO EVALUATION FROM CLINIC

Facility

$94.00

Service Code	HCPCS 99211
Hospital Charge Code	1010111
Hospital Revenue Code	760
Min. Negotiated Rate	$65.80
Max. Negotiated Rate	$94.00
Rate for Payer: Aetna Commercial	$89.30
Rate for Payer: Aetna Medicare	$84.60
Rate for Payer: BCBS MT CHIP	$84.60
Rate for Payer: BCBS MT Closed Plan Network	$89.30
Rate for Payer: BCBS MT HealthLink	$84.60
Rate for Payer: BCBS MT Medicare	$84.60
Rate for Payer: BCBS MT POS	$89.30
Rate for Payer: BCBS MT Traditional	$94.00
Rate for Payer: Cash Price	$84.60
Rate for Payer: Cigna Commercial	$89.30
Rate for Payer: Cigna Medicare	$84.60
Rate for Payer: Medicaid All Medicaid	$86.48
Rate for Payer: Medicare All Medicare	$65.80
Rate for Payer: Monida Allegiance	$89.30
Rate for Payer: Monida First Choice Health	$91.18
Rate for Payer: Monida Montana Health Co-op	$89.30
Rate for Payer: Monida PacificSource	$89.30

ER ROOM/OP ROOM BRIEF 99281

Facility

$279.00

Service Code	HCPCS 99281 25
Hospital Charge Code	1010107
Hospital Revenue Code	450
Min. Negotiated Rate	$195.30
Max. Negotiated Rate	$279.00
Rate for Payer: Aetna Commercial	$265.05
Rate for Payer: Aetna Medicare	$251.10
Rate for Payer: BCBS MT CHIP	$251.10
Rate for Payer: BCBS MT Closed Plan Network	$265.05
Rate for Payer: BCBS MT HealthLink	$251.10
Rate for Payer: BCBS MT Medicare	$251.10
Rate for Payer: BCBS MT POS	$265.05
Rate for Payer: BCBS MT Traditional	$279.00
Rate for Payer: Cash Price	$251.10
Rate for Payer: Cigna Commercial	$265.05
Rate for Payer: Cigna Medicare	$251.10
Rate for Payer: Medicaid All Medicaid	$256.68
Rate for Payer: Medicare All Medicare	$195.30
Rate for Payer: Monida Allegiance	$265.05
Rate for Payer: Monida First Choice Health	$270.63
Rate for Payer: Monida Montana Health Co-op	$265.05
Rate for Payer: Monida PacificSource	$265.05

ER ROOM/OP ROOM BRIEF 99281

Facility

$279.00

Service Code	HCPCS 99281 25
Hospital Charge Code	1010107
Hospital Revenue Code	450
Min. Negotiated Rate	$195.30
Max. Negotiated Rate	$279.00
Rate for Payer: Aetna Commercial	$265.05
Rate for Payer: Aetna Medicare	$251.10
Rate for Payer: BCBS MT CHIP	$251.10
Rate for Payer: BCBS MT Closed Plan Network	$265.05
Rate for Payer: BCBS MT HealthLink	$251.10
Rate for Payer: BCBS MT Medicare	$251.10
Rate for Payer: BCBS MT POS	$265.05
Rate for Payer: BCBS MT Traditional	$279.00
Rate for Payer: Cash Price	$251.10
Rate for Payer: Cigna Commercial	$265.05
Rate for Payer: Cigna Medicare	$251.10
Rate for Payer: Medicaid All Medicaid	$256.68
Rate for Payer: Medicare All Medicare	$195.30
Rate for Payer: Monida Allegiance	$265.05
Rate for Payer: Monida First Choice Health	$270.63
Rate for Payer: Monida Montana Health Co-op	$265.05
Rate for Payer: Monida PacificSource	$265.05

ER ROOM/OP ROOM COMPREHENSIVE 99285

Facility

$1,823.00

Service Code	HCPCS 99285 25
Hospital Charge Code	1010106
Hospital Revenue Code	450
Min. Negotiated Rate	$1,276.10
Max. Negotiated Rate	$1,823.00
Rate for Payer: Aetna Commercial	$1,731.85
Rate for Payer: Aetna Medicare	$1,640.70
Rate for Payer: BCBS MT CHIP	$1,640.70
Rate for Payer: BCBS MT Closed Plan Network	$1,731.85
Rate for Payer: BCBS MT HealthLink	$1,640.70
Rate for Payer: BCBS MT Medicare	$1,640.70
Rate for Payer: BCBS MT POS	$1,731.85
Rate for Payer: BCBS MT Traditional	$1,823.00
Rate for Payer: Cash Price	$1,640.70
Rate for Payer: Cigna Commercial	$1,731.85
Rate for Payer: Cigna Medicare	$1,640.70
Rate for Payer: Medicaid All Medicaid	$1,677.16
Rate for Payer: Medicare All Medicare	$1,276.10
Rate for Payer: Monida Allegiance	$1,731.85
Rate for Payer: Monida First Choice Health	$1,768.31
Rate for Payer: Monida Montana Health Co-op	$1,731.85
Rate for Payer: Monida PacificSource	$1,731.85

ER ROOM/OP ROOM COMPREHENSIVE 99285

Facility

$1,823.00

Service Code	HCPCS 99285 25
Hospital Charge Code	1010106
Hospital Revenue Code	450
Min. Negotiated Rate	$1,276.10
Max. Negotiated Rate	$1,823.00
Rate for Payer: Aetna Commercial	$1,731.85
Rate for Payer: Aetna Medicare	$1,640.70
Rate for Payer: BCBS MT CHIP	$1,640.70
Rate for Payer: BCBS MT Closed Plan Network	$1,731.85
Rate for Payer: BCBS MT HealthLink	$1,640.70
Rate for Payer: BCBS MT Medicare	$1,640.70
Rate for Payer: BCBS MT POS	$1,731.85
Rate for Payer: BCBS MT Traditional	$1,823.00
Rate for Payer: Cash Price	$1,640.70
Rate for Payer: Cigna Commercial	$1,731.85
Rate for Payer: Cigna Medicare	$1,640.70
Rate for Payer: Medicaid All Medicaid	$1,677.16
Rate for Payer: Medicare All Medicare	$1,276.10
Rate for Payer: Monida Allegiance	$1,731.85
Rate for Payer: Monida First Choice Health	$1,768.31
Rate for Payer: Monida Montana Health Co-op	$1,731.85
Rate for Payer: Monida PacificSource	$1,731.85

ER ROOM/OP ROOM EXTENDED 99284

Facility

$1,221.00

Service Code	HCPCS 99284 25
Hospital Charge Code	1010105
Hospital Revenue Code	450
Min. Negotiated Rate	$854.70
Max. Negotiated Rate	$1,221.00
Rate for Payer: Aetna Commercial	$1,159.95
Rate for Payer: Aetna Medicare	$1,098.90
Rate for Payer: BCBS MT CHIP	$1,098.90
Rate for Payer: BCBS MT Closed Plan Network	$1,159.95
Rate for Payer: BCBS MT HealthLink	$1,098.90
Rate for Payer: BCBS MT Medicare	$1,098.90
Rate for Payer: BCBS MT POS	$1,159.95
Rate for Payer: BCBS MT Traditional	$1,221.00
Rate for Payer: Cash Price	$1,098.90
Rate for Payer: Cigna Commercial	$1,159.95
Rate for Payer: Cigna Medicare	$1,098.90
Rate for Payer: Medicaid All Medicaid	$1,123.32
Rate for Payer: Medicare All Medicare	$854.70
Rate for Payer: Monida Allegiance	$1,159.95
Rate for Payer: Monida First Choice Health	$1,184.37
Rate for Payer: Monida Montana Health Co-op	$1,159.95
Rate for Payer: Monida PacificSource	$1,159.95

ER ROOM/OP ROOM EXTENDED 99284

Facility

$1,221.00

Service Code	HCPCS 99284 25
Hospital Charge Code	1010105
Hospital Revenue Code	450
Min. Negotiated Rate	$854.70
Max. Negotiated Rate	$1,221.00
Rate for Payer: Aetna Commercial	$1,159.95
Rate for Payer: Aetna Medicare	$1,098.90
Rate for Payer: BCBS MT CHIP	$1,098.90
Rate for Payer: BCBS MT Closed Plan Network	$1,159.95
Rate for Payer: BCBS MT HealthLink	$1,098.90
Rate for Payer: BCBS MT Medicare	$1,098.90
Rate for Payer: BCBS MT POS	$1,159.95
Rate for Payer: BCBS MT Traditional	$1,221.00
Rate for Payer: Cash Price	$1,098.90
Rate for Payer: Cigna Commercial	$1,159.95
Rate for Payer: Cigna Medicare	$1,098.90
Rate for Payer: Medicaid All Medicaid	$1,123.32
Rate for Payer: Medicare All Medicare	$854.70
Rate for Payer: Monida Allegiance	$1,159.95
Rate for Payer: Monida First Choice Health	$1,184.37
Rate for Payer: Monida Montana Health Co-op	$1,159.95
Rate for Payer: Monida PacificSource	$1,159.95

ER ROOM/OP ROOM INTERMEDIATE 99283

Facility

$758.00

Service Code	HCPCS 99283 25
Hospital Charge Code	1010101
Hospital Revenue Code	450
Min. Negotiated Rate	$530.60
Max. Negotiated Rate	$758.00
Rate for Payer: Aetna Commercial	$720.10
Rate for Payer: Aetna Medicare	$682.20
Rate for Payer: BCBS MT CHIP	$682.20
Rate for Payer: BCBS MT Closed Plan Network	$720.10
Rate for Payer: BCBS MT HealthLink	$682.20
Rate for Payer: BCBS MT Medicare	$682.20
Rate for Payer: BCBS MT POS	$720.10
Rate for Payer: BCBS MT Traditional	$758.00
Rate for Payer: Cash Price	$682.20
Rate for Payer: Cigna Commercial	$720.10
Rate for Payer: Cigna Medicare	$682.20
Rate for Payer: Medicaid All Medicaid	$697.36
Rate for Payer: Medicare All Medicare	$530.60
Rate for Payer: Monida Allegiance	$720.10
Rate for Payer: Monida First Choice Health	$735.26
Rate for Payer: Monida Montana Health Co-op	$720.10
Rate for Payer: Monida PacificSource	$720.10

ER ROOM/OP ROOM INTERMEDIATE 99283

Facility

$758.00

Service Code	HCPCS 99283 25
Hospital Charge Code	1010101
Hospital Revenue Code	450
Min. Negotiated Rate	$530.60
Max. Negotiated Rate	$758.00
Rate for Payer: Aetna Commercial	$720.10
Rate for Payer: Aetna Medicare	$682.20
Rate for Payer: BCBS MT CHIP	$682.20
Rate for Payer: BCBS MT Closed Plan Network	$720.10
Rate for Payer: BCBS MT HealthLink	$682.20
Rate for Payer: BCBS MT Medicare	$682.20
Rate for Payer: BCBS MT POS	$720.10
Rate for Payer: BCBS MT Traditional	$758.00
Rate for Payer: Cash Price	$682.20
Rate for Payer: Cigna Commercial	$720.10
Rate for Payer: Cigna Medicare	$682.20
Rate for Payer: Medicaid All Medicaid	$697.36
Rate for Payer: Medicare All Medicare	$530.60
Rate for Payer: Monida Allegiance	$720.10
Rate for Payer: Monida First Choice Health	$735.26
Rate for Payer: Monida Montana Health Co-op	$720.10
Rate for Payer: Monida PacificSource	$720.10

ER ROOM/OP ROOM LIMITED 99282

Facility

$463.00

Service Code	HCPCS 99282 25
Hospital Charge Code	1010100
Hospital Revenue Code	450
Min. Negotiated Rate	$324.10
Max. Negotiated Rate	$463.00
Rate for Payer: Aetna Commercial	$439.85
Rate for Payer: Aetna Medicare	$416.70
Rate for Payer: BCBS MT CHIP	$416.70
Rate for Payer: BCBS MT Closed Plan Network	$439.85
Rate for Payer: BCBS MT HealthLink	$416.70
Rate for Payer: BCBS MT Medicare	$416.70
Rate for Payer: BCBS MT POS	$439.85
Rate for Payer: BCBS MT Traditional	$463.00
Rate for Payer: Cash Price	$416.70
Rate for Payer: Cigna Commercial	$439.85
Rate for Payer: Cigna Medicare	$416.70
Rate for Payer: Medicaid All Medicaid	$425.96
Rate for Payer: Medicare All Medicare	$324.10
Rate for Payer: Monida Allegiance	$439.85
Rate for Payer: Monida First Choice Health	$449.11
Rate for Payer: Monida Montana Health Co-op	$439.85
Rate for Payer: Monida PacificSource	$439.85

ER ROOM/OP ROOM LIMITED 99282

Facility

$463.00

Service Code	HCPCS 99282 25
Hospital Charge Code	1010100
Hospital Revenue Code	450
Min. Negotiated Rate	$324.10
Max. Negotiated Rate	$463.00
Rate for Payer: Aetna Commercial	$439.85
Rate for Payer: Aetna Medicare	$416.70
Rate for Payer: BCBS MT CHIP	$416.70
Rate for Payer: BCBS MT Closed Plan Network	$439.85
Rate for Payer: BCBS MT HealthLink	$416.70
Rate for Payer: BCBS MT Medicare	$416.70
Rate for Payer: BCBS MT POS	$439.85
Rate for Payer: BCBS MT Traditional	$463.00
Rate for Payer: Cash Price	$416.70
Rate for Payer: Cigna Commercial	$439.85
Rate for Payer: Cigna Medicare	$416.70
Rate for Payer: Medicaid All Medicaid	$425.96
Rate for Payer: Medicare All Medicare	$324.10
Rate for Payer: Monida Allegiance	$439.85
Rate for Payer: Monida First Choice Health	$449.11
Rate for Payer: Monida Montana Health Co-op	$439.85
Rate for Payer: Monida PacificSource	$439.85

ER TREAT ELBOW DISLOCATION

Facility

$440.00

Service Code	HCPCS 24640
Hospital Charge Code	1024640
Hospital Revenue Code	450
Min. Negotiated Rate	$308.00
Max. Negotiated Rate	$440.00
Rate for Payer: Aetna Commercial	$418.00
Rate for Payer: Aetna Medicare	$396.00
Rate for Payer: BCBS MT CHIP	$396.00
Rate for Payer: BCBS MT Closed Plan Network	$418.00
Rate for Payer: BCBS MT HealthLink	$396.00
Rate for Payer: BCBS MT Medicare	$396.00
Rate for Payer: BCBS MT POS	$418.00
Rate for Payer: BCBS MT Traditional	$440.00
Rate for Payer: Cash Price	$396.00
Rate for Payer: Cigna Commercial	$418.00
Rate for Payer: Cigna Medicare	$396.00
Rate for Payer: Medicaid All Medicaid	$404.80
Rate for Payer: Medicare All Medicare	$308.00
Rate for Payer: Monida Allegiance	$418.00
Rate for Payer: Monida First Choice Health	$426.80
Rate for Payer: Monida Montana Health Co-op	$418.00
Rate for Payer: Monida PacificSource	$418.00

ER TREAT ELBOW DISLOCATION

Facility

$440.00

Service Code	HCPCS 24640
Hospital Charge Code	1024640
Hospital Revenue Code	450
Min. Negotiated Rate	$308.00
Max. Negotiated Rate	$440.00
Rate for Payer: Aetna Commercial	$418.00
Rate for Payer: Aetna Medicare	$396.00
Rate for Payer: BCBS MT CHIP	$396.00
Rate for Payer: BCBS MT Closed Plan Network	$418.00
Rate for Payer: BCBS MT HealthLink	$396.00
Rate for Payer: BCBS MT Medicare	$396.00
Rate for Payer: BCBS MT POS	$418.00
Rate for Payer: BCBS MT Traditional	$440.00
Rate for Payer: Cash Price	$396.00
Rate for Payer: Cigna Commercial	$418.00
Rate for Payer: Cigna Medicare	$396.00
Rate for Payer: Medicaid All Medicaid	$404.80
Rate for Payer: Medicare All Medicare	$308.00
Rate for Payer: Monida Allegiance	$418.00
Rate for Payer: Monida First Choice Health	$426.80
Rate for Payer: Monida Montana Health Co-op	$418.00
Rate for Payer: Monida PacificSource	$418.00

ER TREAT SHOULDER DISLOCATION

Facility

$1,195.00

Service Code	HCPCS 23655
Hospital Charge Code	1023655
Hospital Revenue Code	450
Min. Negotiated Rate	$836.50
Max. Negotiated Rate	$1,195.00
Rate for Payer: Aetna Commercial	$1,135.25
Rate for Payer: Aetna Medicare	$1,075.50
Rate for Payer: BCBS MT CHIP	$1,075.50
Rate for Payer: BCBS MT Closed Plan Network	$1,135.25
Rate for Payer: BCBS MT HealthLink	$1,075.50
Rate for Payer: BCBS MT Medicare	$1,075.50
Rate for Payer: BCBS MT POS	$1,135.25
Rate for Payer: BCBS MT Traditional	$1,195.00
Rate for Payer: Cash Price	$1,075.50
Rate for Payer: Cigna Commercial	$1,135.25
Rate for Payer: Cigna Medicare	$1,075.50
Rate for Payer: Medicaid All Medicaid	$1,099.40
Rate for Payer: Medicare All Medicare	$836.50
Rate for Payer: Monida Allegiance	$1,135.25
Rate for Payer: Monida First Choice Health	$1,159.15
Rate for Payer: Monida Montana Health Co-op	$1,135.25
Rate for Payer: Monida PacificSource	$1,135.25

ER TREAT SHOULDER DISLOCATION

Facility

$1,195.00

Service Code	HCPCS 23655
Hospital Charge Code	1023655
Hospital Revenue Code	450
Min. Negotiated Rate	$836.50
Max. Negotiated Rate	$1,195.00
Rate for Payer: Aetna Commercial	$1,135.25
Rate for Payer: Aetna Medicare	$1,075.50
Rate for Payer: BCBS MT CHIP	$1,075.50
Rate for Payer: BCBS MT Closed Plan Network	$1,135.25
Rate for Payer: BCBS MT HealthLink	$1,075.50
Rate for Payer: BCBS MT Medicare	$1,075.50
Rate for Payer: BCBS MT POS	$1,135.25
Rate for Payer: BCBS MT Traditional	$1,195.00
Rate for Payer: Cash Price	$1,075.50
Rate for Payer: Cigna Commercial	$1,135.25
Rate for Payer: Cigna Medicare	$1,075.50
Rate for Payer: Medicaid All Medicaid	$1,099.40
Rate for Payer: Medicare All Medicare	$836.50
Rate for Payer: Monida Allegiance	$1,135.25
Rate for Payer: Monida First Choice Health	$1,159.15
Rate for Payer: Monida Montana Health Co-op	$1,135.25
Rate for Payer: Monida PacificSource	$1,135.25

ER TRIGEMINAL NERVE BLOCK 64400

Facility

$815.00

Service Code	HCPCS 64400
Hospital Charge Code	1064400
Hospital Revenue Code	450
Min. Negotiated Rate	$570.50
Max. Negotiated Rate	$815.00
Rate for Payer: Aetna Commercial	$774.25
Rate for Payer: Aetna Medicare	$733.50
Rate for Payer: BCBS MT CHIP	$733.50
Rate for Payer: BCBS MT Closed Plan Network	$774.25
Rate for Payer: BCBS MT HealthLink	$733.50
Rate for Payer: BCBS MT Medicare	$733.50
Rate for Payer: BCBS MT POS	$774.25
Rate for Payer: BCBS MT Traditional	$815.00
Rate for Payer: Cash Price	$733.50
Rate for Payer: Cigna Commercial	$774.25
Rate for Payer: Cigna Medicare	$733.50
Rate for Payer: Medicaid All Medicaid	$749.80
Rate for Payer: Medicare All Medicare	$570.50
Rate for Payer: Monida Allegiance	$774.25
Rate for Payer: Monida First Choice Health	$790.55
Rate for Payer: Monida Montana Health Co-op	$774.25
Rate for Payer: Monida PacificSource	$774.25

ER TRIGEMINAL NERVE BLOCK 64400

Facility

$815.00

Service Code	HCPCS 64400
Hospital Charge Code	1064400
Hospital Revenue Code	450
Min. Negotiated Rate	$570.50
Max. Negotiated Rate	$815.00
Rate for Payer: Aetna Commercial	$774.25
Rate for Payer: Aetna Medicare	$733.50
Rate for Payer: BCBS MT CHIP	$733.50
Rate for Payer: BCBS MT Closed Plan Network	$774.25
Rate for Payer: BCBS MT HealthLink	$733.50
Rate for Payer: BCBS MT Medicare	$733.50
Rate for Payer: BCBS MT POS	$774.25
Rate for Payer: BCBS MT Traditional	$815.00
Rate for Payer: Cash Price	$733.50
Rate for Payer: Cigna Commercial	$774.25
Rate for Payer: Cigna Medicare	$733.50
Rate for Payer: Medicaid All Medicaid	$749.80
Rate for Payer: Medicare All Medicare	$570.50
Rate for Payer: Monida Allegiance	$774.25
Rate for Payer: Monida First Choice Health	$790.55
Rate for Payer: Monida Montana Health Co-op	$774.25
Rate for Payer: Monida PacificSource	$774.25

ER TX BURN INITIAL 1ST DEGREE

Facility

$290.00

Service Code	HCPCS 16000
Hospital Charge Code	1016000
Hospital Revenue Code	450
Min. Negotiated Rate	$203.00
Max. Negotiated Rate	$290.00
Rate for Payer: Aetna Commercial	$275.50
Rate for Payer: Aetna Medicare	$261.00
Rate for Payer: BCBS MT CHIP	$261.00
Rate for Payer: BCBS MT Closed Plan Network	$275.50
Rate for Payer: BCBS MT HealthLink	$261.00
Rate for Payer: BCBS MT Medicare	$261.00
Rate for Payer: BCBS MT POS	$275.50
Rate for Payer: BCBS MT Traditional	$290.00
Rate for Payer: Cash Price	$261.00
Rate for Payer: Cigna Commercial	$275.50
Rate for Payer: Cigna Medicare	$261.00
Rate for Payer: Medicaid All Medicaid	$266.80
Rate for Payer: Medicare All Medicare	$203.00
Rate for Payer: Monida Allegiance	$275.50
Rate for Payer: Monida First Choice Health	$281.30
Rate for Payer: Monida Montana Health Co-op	$275.50
Rate for Payer: Monida PacificSource	$275.50

ER TX BURN INITIAL 1ST DEGREE

Facility

$290.00

Service Code	HCPCS 16000
Hospital Charge Code	1016000
Hospital Revenue Code	450
Min. Negotiated Rate	$203.00
Max. Negotiated Rate	$290.00
Rate for Payer: Aetna Commercial	$275.50
Rate for Payer: Aetna Medicare	$261.00
Rate for Payer: BCBS MT CHIP	$261.00
Rate for Payer: BCBS MT Closed Plan Network	$275.50
Rate for Payer: BCBS MT HealthLink	$261.00
Rate for Payer: BCBS MT Medicare	$261.00
Rate for Payer: BCBS MT POS	$275.50
Rate for Payer: BCBS MT Traditional	$290.00
Rate for Payer: Cash Price	$261.00
Rate for Payer: Cigna Commercial	$275.50
Rate for Payer: Cigna Medicare	$261.00
Rate for Payer: Medicaid All Medicaid	$266.80
Rate for Payer: Medicare All Medicare	$203.00
Rate for Payer: Monida Allegiance	$275.50
Rate for Payer: Monida First Choice Health	$281.30
Rate for Payer: Monida Montana Health Co-op	$275.50
Rate for Payer: Monida PacificSource	$275.50

ER TX DISLOC(I-P)JT W/O ANES W/MANIP CLO

Facility

$724.00

Service Code	HCPCS 26770
Hospital Charge Code	1026770
Hospital Revenue Code	450
Min. Negotiated Rate	$506.80
Max. Negotiated Rate	$724.00
Rate for Payer: Aetna Commercial	$687.80
Rate for Payer: Aetna Medicare	$651.60
Rate for Payer: BCBS MT CHIP	$651.60
Rate for Payer: BCBS MT Closed Plan Network	$687.80
Rate for Payer: BCBS MT HealthLink	$651.60
Rate for Payer: BCBS MT Medicare	$651.60
Rate for Payer: BCBS MT POS	$687.80
Rate for Payer: BCBS MT Traditional	$724.00
Rate for Payer: Cash Price	$651.60
Rate for Payer: Cigna Commercial	$687.80
Rate for Payer: Cigna Medicare	$651.60
Rate for Payer: Medicaid All Medicaid	$666.08
Rate for Payer: Medicare All Medicare	$506.80
Rate for Payer: Monida Allegiance	$687.80
Rate for Payer: Monida First Choice Health	$702.28
Rate for Payer: Monida Montana Health Co-op	$687.80
Rate for Payer: Monida PacificSource	$687.80

Know your out-of-pocket cost for care.

All Charges