Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

ER APPLY SHORT LEG CAST

Facility

$295.00

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

ER CARDIOPULMONARY RESUSCITATION

Facility

$875.00

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

ER CARDIOPULMONARY RESUSCITATION

Facility

$875.00

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

ER CARDIOVERSION ELECTIVE EXTERNAL(DEFIB

Facility

$1,537.00

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

ER CARDIOVERSION ELECTIVE EXTERNAL(DEFIB

Facility

$1,537.00

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

ER CATH ASP NASOTRACHEAL

Facility

$198.00

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

ER CATH ASP NASOTRACHEAL

Facility

$198.00

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

ER CLOSED DISLOCATION ELBOW

Facility

$579.00

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

ER CLOSED DISLOCATION ELBOW

Facility

$579.00

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

ER CLOSED DISLOCATION OF THE TARSAL BONE

Facility

$428.00

Service Code	CPT 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 TARSAL BONE

Facility

$428.00

Service Code	CPT 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	CPT 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	CPT 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	CPT 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	CPT 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 DISLOC W/O ANESTHIA 27550

Facility

$579.00

Service Code	CPT 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 DISLOC W/O ANESTHIA 27550

Facility

$579.00

Service Code	CPT 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	CPT 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	CPT 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	CPT 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	CPT 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	CPT 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	CPT 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	CPT 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	CPT 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

Know your out-of-pocket cost for care.

All Charges