Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

ER INTUBATION, ENDOTRACHEAL 31500

Facility

$641.00

Service Code	CPT 31500
Hospital Charge Code	1031500
Hospital Revenue Code	450
Min. Negotiated Rate	$448.70
Max. Negotiated Rate	$641.00
Rate for Payer: Aetna Commercial	$608.95
Rate for Payer: Aetna Medicare	$576.90
Rate for Payer: BCBS MT CHIP	$576.90
Rate for Payer: BCBS MT Closed Plan Network	$608.95
Rate for Payer: BCBS MT HealthLink	$576.90
Rate for Payer: BCBS MT Medicare	$576.90
Rate for Payer: BCBS MT POS	$608.95
Rate for Payer: BCBS MT Traditional	$641.00
Rate for Payer: Cash Price	$576.90
Rate for Payer: Cigna Commercial	$608.95
Rate for Payer: Cigna Medicare	$576.90
Rate for Payer: Medicaid All Medicaid	$589.72
Rate for Payer: Medicare All Medicare	$448.70
Rate for Payer: Monida Allegiance	$608.95
Rate for Payer: Monida First Choice Health	$621.77
Rate for Payer: Monida Montana Health Co-op	$608.95
Rate for Payer: Monida PacificSource	$608.95

ER MISCELLANEOUS

Facility

$914.00

Hospital Charge Code	1099999
Hospital Revenue Code	450
Min. Negotiated Rate	$639.80
Max. Negotiated Rate	$914.00
Rate for Payer: Aetna Commercial	$868.30
Rate for Payer: Aetna Medicare	$822.60
Rate for Payer: BCBS MT CHIP	$822.60
Rate for Payer: BCBS MT Closed Plan Network	$868.30
Rate for Payer: BCBS MT HealthLink	$822.60
Rate for Payer: BCBS MT Medicare	$822.60
Rate for Payer: BCBS MT POS	$868.30
Rate for Payer: BCBS MT Traditional	$914.00
Rate for Payer: Cash Price	$822.60
Rate for Payer: Cigna Commercial	$868.30
Rate for Payer: Cigna Medicare	$822.60
Rate for Payer: Medicaid All Medicaid	$840.88
Rate for Payer: Medicare All Medicare	$639.80
Rate for Payer: Monida Allegiance	$868.30
Rate for Payer: Monida First Choice Health	$886.58
Rate for Payer: Monida Montana Health Co-op	$868.30
Rate for Payer: Monida PacificSource	$868.30

ER MISCELLANEOUS

Facility

$914.00

Hospital Charge Code	1099999
Hospital Revenue Code	450
Min. Negotiated Rate	$639.80
Max. Negotiated Rate	$914.00
Rate for Payer: Aetna Commercial	$868.30
Rate for Payer: Aetna Medicare	$822.60
Rate for Payer: BCBS MT CHIP	$822.60
Rate for Payer: BCBS MT Closed Plan Network	$868.30
Rate for Payer: BCBS MT HealthLink	$822.60
Rate for Payer: BCBS MT Medicare	$822.60
Rate for Payer: BCBS MT POS	$868.30
Rate for Payer: BCBS MT Traditional	$914.00
Rate for Payer: Cash Price	$822.60
Rate for Payer: Cigna Commercial	$868.30
Rate for Payer: Cigna Medicare	$822.60
Rate for Payer: Medicaid All Medicaid	$840.88
Rate for Payer: Medicare All Medicare	$639.80
Rate for Payer: Monida Allegiance	$868.30
Rate for Payer: Monida First Choice Health	$886.58
Rate for Payer: Monida Montana Health Co-op	$868.30
Rate for Payer: Monida PacificSource	$868.30

ER MODERATE SEDATION SERVICES

Facility

$324.00

Service Code	CPT 99152
Hospital Charge Code	1099152
Hospital Revenue Code	450
Min. Negotiated Rate	$226.80
Max. Negotiated Rate	$324.00
Rate for Payer: Aetna Commercial	$307.80
Rate for Payer: Aetna Medicare	$291.60
Rate for Payer: BCBS MT CHIP	$291.60
Rate for Payer: BCBS MT Closed Plan Network	$307.80
Rate for Payer: BCBS MT HealthLink	$291.60
Rate for Payer: BCBS MT Medicare	$291.60
Rate for Payer: BCBS MT POS	$307.80
Rate for Payer: BCBS MT Traditional	$324.00
Rate for Payer: Cash Price	$291.60
Rate for Payer: Cigna Commercial	$307.80
Rate for Payer: Cigna Medicare	$291.60
Rate for Payer: Medicaid All Medicaid	$298.08
Rate for Payer: Medicare All Medicare	$226.80
Rate for Payer: Monida Allegiance	$307.80
Rate for Payer: Monida First Choice Health	$314.28
Rate for Payer: Monida Montana Health Co-op	$307.80
Rate for Payer: Monida PacificSource	$307.80

ER MODERATE SEDATION SERVICES

Facility

$324.00

Service Code	CPT 99152
Hospital Charge Code	1099152
Hospital Revenue Code	450
Min. Negotiated Rate	$226.80
Max. Negotiated Rate	$324.00
Rate for Payer: Aetna Commercial	$307.80
Rate for Payer: Aetna Medicare	$291.60
Rate for Payer: BCBS MT CHIP	$291.60
Rate for Payer: BCBS MT Closed Plan Network	$307.80
Rate for Payer: BCBS MT HealthLink	$291.60
Rate for Payer: BCBS MT Medicare	$291.60
Rate for Payer: BCBS MT POS	$307.80
Rate for Payer: BCBS MT Traditional	$324.00
Rate for Payer: Cash Price	$291.60
Rate for Payer: Cigna Commercial	$307.80
Rate for Payer: Cigna Medicare	$291.60
Rate for Payer: Medicaid All Medicaid	$298.08
Rate for Payer: Medicare All Medicare	$226.80
Rate for Payer: Monida Allegiance	$307.80
Rate for Payer: Monida First Choice Health	$314.28
Rate for Payer: Monida Montana Health Co-op	$307.80
Rate for Payer: Monida PacificSource	$307.80

ER N BLOCK OF PERIPHERAL BRANCH

Facility

$904.00

Service Code	CPT 64450
Hospital Charge Code	1064450
Hospital Revenue Code	450
Min. Negotiated Rate	$632.80
Max. Negotiated Rate	$904.00
Rate for Payer: Aetna Commercial	$858.80
Rate for Payer: Aetna Medicare	$813.60
Rate for Payer: BCBS MT CHIP	$813.60
Rate for Payer: BCBS MT Closed Plan Network	$858.80
Rate for Payer: BCBS MT HealthLink	$813.60
Rate for Payer: BCBS MT Medicare	$813.60
Rate for Payer: BCBS MT POS	$858.80
Rate for Payer: BCBS MT Traditional	$904.00
Rate for Payer: Cash Price	$813.60
Rate for Payer: Cigna Commercial	$858.80
Rate for Payer: Cigna Medicare	$813.60
Rate for Payer: Medicaid All Medicaid	$831.68
Rate for Payer: Medicare All Medicare	$632.80
Rate for Payer: Monida Allegiance	$858.80
Rate for Payer: Monida First Choice Health	$876.88
Rate for Payer: Monida Montana Health Co-op	$858.80
Rate for Payer: Monida PacificSource	$858.80

ER N BLOCK OF PERIPHERAL BRANCH

Facility

$904.00

Service Code	CPT 64450
Hospital Charge Code	1064450
Hospital Revenue Code	450
Min. Negotiated Rate	$632.80
Max. Negotiated Rate	$904.00
Rate for Payer: Aetna Commercial	$858.80
Rate for Payer: Aetna Medicare	$813.60
Rate for Payer: BCBS MT CHIP	$813.60
Rate for Payer: BCBS MT Closed Plan Network	$858.80
Rate for Payer: BCBS MT HealthLink	$813.60
Rate for Payer: BCBS MT Medicare	$813.60
Rate for Payer: BCBS MT POS	$858.80
Rate for Payer: BCBS MT Traditional	$904.00
Rate for Payer: Cash Price	$813.60
Rate for Payer: Cigna Commercial	$858.80
Rate for Payer: Cigna Medicare	$813.60
Rate for Payer: Medicaid All Medicaid	$831.68
Rate for Payer: Medicare All Medicare	$632.80
Rate for Payer: Monida Allegiance	$858.80
Rate for Payer: Monida First Choice Health	$876.88
Rate for Payer: Monida Montana Health Co-op	$858.80
Rate for Payer: Monida PacificSource	$858.80

ERPAK HYDROCODONE/APAP [5/325 MG]4 TAB

Facility

$32.00

Service Code	HCPCS J8499
Hospital Charge Code	3000157
Hospital Revenue Code	250
Min. Negotiated Rate	$22.40
Max. Negotiated Rate	$32.00
Rate for Payer: Aetna Commercial	$30.40
Rate for Payer: Aetna Medicare	$28.80
Rate for Payer: BCBS MT CHIP	$28.80
Rate for Payer: BCBS MT Closed Plan Network	$30.40
Rate for Payer: BCBS MT HealthLink	$28.80
Rate for Payer: BCBS MT Medicare	$28.80
Rate for Payer: BCBS MT POS	$30.40
Rate for Payer: BCBS MT Traditional	$32.00
Rate for Payer: Cash Price	$28.80
Rate for Payer: Cigna Commercial	$30.40
Rate for Payer: Cigna Medicare	$28.80
Rate for Payer: Medicaid All Medicaid	$29.44
Rate for Payer: Medicare All Medicare	$22.40
Rate for Payer: Monida Allegiance	$30.40
Rate for Payer: Monida First Choice Health	$31.04
Rate for Payer: Monida Montana Health Co-op	$30.40
Rate for Payer: Monida PacificSource	$30.40

ERPAK HYDROCODONE/APAP [5/325 MG]4 TAB

Facility

$32.00

Service Code	HCPCS J8499
Hospital Charge Code	3000157
Hospital Revenue Code	250
Min. Negotiated Rate	$22.40
Max. Negotiated Rate	$32.00
Rate for Payer: Aetna Commercial	$30.40
Rate for Payer: Aetna Medicare	$28.80
Rate for Payer: BCBS MT CHIP	$28.80
Rate for Payer: BCBS MT Closed Plan Network	$30.40
Rate for Payer: BCBS MT HealthLink	$28.80
Rate for Payer: BCBS MT Medicare	$28.80
Rate for Payer: BCBS MT POS	$30.40
Rate for Payer: BCBS MT Traditional	$32.00
Rate for Payer: Cash Price	$28.80
Rate for Payer: Cigna Commercial	$30.40
Rate for Payer: Cigna Medicare	$28.80
Rate for Payer: Medicaid All Medicaid	$29.44
Rate for Payer: Medicare All Medicare	$22.40
Rate for Payer: Monida Allegiance	$30.40
Rate for Payer: Monida First Choice Health	$31.04
Rate for Payer: Monida Montana Health Co-op	$30.40
Rate for Payer: Monida PacificSource	$30.40

ERPAK ONDANSETRON ODT [4 MG] 6 TAB PACKS

Facility

$48.00

Service Code	HCPCS S0119
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 ONDANSETRON ODT [4 MG] 6 TAB PACKS

Facility

$48.00

Service Code	HCPCS S0119
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 J8499
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 J8499
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	CPT 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	CPT 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	CPT 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	CPT 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	CPT 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	CPT 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	CPT 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	CPT 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	CPT 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	CPT 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	CPT 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	CPT 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

Know your out-of-pocket cost for care.

All Charges