Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

ER ROOM/OP ROOM COMPREHENSIVE 99285

Facility

$1,823.00

Service Code	CPT 99285
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	CPT 99284
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	CPT 99284
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	CPT 99283
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	CPT 99283
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	CPT 99282
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	CPT 99282
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	CPT 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	CPT 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	CPT 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	CPT 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	CPT 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	CPT 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	CPT 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	CPT 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	CPT 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

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

Facility

$724.00

Service Code	CPT 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

ER TX DISLOC(M-P)W/ANES W/MANIP CLOSED

Facility

$572.00

Service Code	CPT 26705
Hospital Charge Code	1026705
Hospital Revenue Code	450
Min. Negotiated Rate	$400.40
Max. Negotiated Rate	$572.00
Rate for Payer: Aetna Commercial	$543.40
Rate for Payer: Aetna Medicare	$514.80
Rate for Payer: BCBS MT CHIP	$514.80
Rate for Payer: BCBS MT Closed Plan Network	$543.40
Rate for Payer: BCBS MT HealthLink	$514.80
Rate for Payer: BCBS MT Medicare	$514.80
Rate for Payer: BCBS MT POS	$543.40
Rate for Payer: BCBS MT Traditional	$572.00
Rate for Payer: Cash Price	$514.80
Rate for Payer: Cigna Commercial	$543.40
Rate for Payer: Cigna Medicare	$514.80
Rate for Payer: Medicaid All Medicaid	$526.24
Rate for Payer: Medicare All Medicare	$400.40
Rate for Payer: Monida Allegiance	$543.40
Rate for Payer: Monida First Choice Health	$554.84
Rate for Payer: Monida Montana Health Co-op	$543.40
Rate for Payer: Monida PacificSource	$543.40

ER TX DISLOC(M-P)W/ANES W/MANIP CLOSED

Facility

$572.00

Service Code	CPT 26705
Hospital Charge Code	1026705
Hospital Revenue Code	450
Min. Negotiated Rate	$400.40
Max. Negotiated Rate	$572.00
Rate for Payer: Aetna Commercial	$543.40
Rate for Payer: Aetna Medicare	$514.80
Rate for Payer: BCBS MT CHIP	$514.80
Rate for Payer: BCBS MT Closed Plan Network	$543.40
Rate for Payer: BCBS MT HealthLink	$514.80
Rate for Payer: BCBS MT Medicare	$514.80
Rate for Payer: BCBS MT POS	$543.40
Rate for Payer: BCBS MT Traditional	$572.00
Rate for Payer: Cash Price	$514.80
Rate for Payer: Cigna Commercial	$543.40
Rate for Payer: Cigna Medicare	$514.80
Rate for Payer: Medicaid All Medicaid	$526.24
Rate for Payer: Medicare All Medicare	$400.40
Rate for Payer: Monida Allegiance	$543.40
Rate for Payer: Monida First Choice Health	$554.84
Rate for Payer: Monida Montana Health Co-op	$543.40
Rate for Payer: Monida PacificSource	$543.40

ER TX OF TOE FRACTURE

Facility

$435.00

Service Code	CPT 28515
Hospital Charge Code	1028515
Hospital Revenue Code	450
Min. Negotiated Rate	$304.50
Max. Negotiated Rate	$435.00
Rate for Payer: Aetna Commercial	$413.25
Rate for Payer: Aetna Medicare	$391.50
Rate for Payer: BCBS MT CHIP	$391.50
Rate for Payer: BCBS MT Closed Plan Network	$413.25
Rate for Payer: BCBS MT HealthLink	$391.50
Rate for Payer: BCBS MT Medicare	$391.50
Rate for Payer: BCBS MT POS	$413.25
Rate for Payer: BCBS MT Traditional	$435.00
Rate for Payer: Cash Price	$391.50
Rate for Payer: Cigna Commercial	$413.25
Rate for Payer: Cigna Medicare	$391.50
Rate for Payer: Medicaid All Medicaid	$400.20
Rate for Payer: Medicare All Medicare	$304.50
Rate for Payer: Monida Allegiance	$413.25
Rate for Payer: Monida First Choice Health	$421.95
Rate for Payer: Monida Montana Health Co-op	$413.25
Rate for Payer: Monida PacificSource	$413.25

ER TX OF TOE FRACTURE

Facility

$435.00

Service Code	CPT 28515
Hospital Charge Code	1028515
Hospital Revenue Code	450
Min. Negotiated Rate	$304.50
Max. Negotiated Rate	$435.00
Rate for Payer: Aetna Commercial	$413.25
Rate for Payer: Aetna Medicare	$391.50
Rate for Payer: BCBS MT CHIP	$391.50
Rate for Payer: BCBS MT Closed Plan Network	$413.25
Rate for Payer: BCBS MT HealthLink	$391.50
Rate for Payer: BCBS MT Medicare	$391.50
Rate for Payer: BCBS MT POS	$413.25
Rate for Payer: BCBS MT Traditional	$435.00
Rate for Payer: Cash Price	$391.50
Rate for Payer: Cigna Commercial	$413.25
Rate for Payer: Cigna Medicare	$391.50
Rate for Payer: Medicaid All Medicaid	$400.20
Rate for Payer: Medicare All Medicare	$304.50
Rate for Payer: Monida Allegiance	$413.25
Rate for Payer: Monida First Choice Health	$421.95
Rate for Payer: Monida Montana Health Co-op	$413.25
Rate for Payer: Monida PacificSource	$413.25

ER TX SHOULDER DISLOC W/O ANEST CLOSED

Facility

$597.00

Service Code	CPT 23650
Hospital Charge Code	1023650
Hospital Revenue Code	450
Min. Negotiated Rate	$417.90
Max. Negotiated Rate	$597.00
Rate for Payer: Aetna Commercial	$567.15
Rate for Payer: Aetna Medicare	$537.30
Rate for Payer: BCBS MT CHIP	$537.30
Rate for Payer: BCBS MT Closed Plan Network	$567.15
Rate for Payer: BCBS MT HealthLink	$537.30
Rate for Payer: BCBS MT Medicare	$537.30
Rate for Payer: BCBS MT POS	$567.15
Rate for Payer: BCBS MT Traditional	$597.00
Rate for Payer: Cash Price	$537.30
Rate for Payer: Cigna Commercial	$567.15
Rate for Payer: Cigna Medicare	$537.30
Rate for Payer: Medicaid All Medicaid	$549.24
Rate for Payer: Medicare All Medicare	$417.90
Rate for Payer: Monida Allegiance	$567.15
Rate for Payer: Monida First Choice Health	$579.09
Rate for Payer: Monida Montana Health Co-op	$567.15
Rate for Payer: Monida PacificSource	$567.15

ER TX SHOULDER DISLOC W/O ANEST CLOSED

Facility

$597.00

Service Code	CPT 23650
Hospital Charge Code	1023650
Hospital Revenue Code	450
Min. Negotiated Rate	$417.90
Max. Negotiated Rate	$597.00
Rate for Payer: Aetna Commercial	$567.15
Rate for Payer: Aetna Medicare	$537.30
Rate for Payer: BCBS MT CHIP	$537.30
Rate for Payer: BCBS MT Closed Plan Network	$567.15
Rate for Payer: BCBS MT HealthLink	$537.30
Rate for Payer: BCBS MT Medicare	$537.30
Rate for Payer: BCBS MT POS	$567.15
Rate for Payer: BCBS MT Traditional	$597.00
Rate for Payer: Cash Price	$537.30
Rate for Payer: Cigna Commercial	$567.15
Rate for Payer: Cigna Medicare	$537.30
Rate for Payer: Medicaid All Medicaid	$549.24
Rate for Payer: Medicare All Medicare	$417.90
Rate for Payer: Monida Allegiance	$567.15
Rate for Payer: Monida First Choice Health	$579.09
Rate for Payer: Monida Montana Health Co-op	$567.15
Rate for Payer: Monida PacificSource	$567.15

ERYTHROCYTE SEDIMENTATION RATE, BLOOD

Facility

$58.00

Service Code	CPT 85652
Hospital Charge Code	4085651
Hospital Revenue Code	305
Min. Negotiated Rate	$40.60
Max. Negotiated Rate	$58.00
Rate for Payer: Aetna Commercial	$55.10
Rate for Payer: Aetna Medicare	$52.20
Rate for Payer: BCBS MT CHIP	$52.20
Rate for Payer: BCBS MT Closed Plan Network	$55.10
Rate for Payer: BCBS MT HealthLink	$52.20
Rate for Payer: BCBS MT Medicare	$52.20
Rate for Payer: BCBS MT POS	$55.10
Rate for Payer: BCBS MT Traditional	$58.00
Rate for Payer: Cash Price	$52.20
Rate for Payer: Cigna Commercial	$55.10
Rate for Payer: Cigna Medicare	$52.20
Rate for Payer: Medicaid All Medicaid	$53.36
Rate for Payer: Medicare All Medicare	$40.60
Rate for Payer: Monida Allegiance	$55.10
Rate for Payer: Monida First Choice Health	$56.26
Rate for Payer: Monida Montana Health Co-op	$55.10
Rate for Payer: Monida PacificSource	$55.10

ERYTHROCYTE SEDIMENTATION RATE, BLOOD

Facility

$58.00

Service Code	CPT 85652
Hospital Charge Code	4085651
Hospital Revenue Code	305
Min. Negotiated Rate	$40.60
Max. Negotiated Rate	$58.00
Rate for Payer: Aetna Commercial	$55.10
Rate for Payer: Aetna Medicare	$52.20
Rate for Payer: BCBS MT CHIP	$52.20
Rate for Payer: BCBS MT Closed Plan Network	$55.10
Rate for Payer: BCBS MT HealthLink	$52.20
Rate for Payer: BCBS MT Medicare	$52.20
Rate for Payer: BCBS MT POS	$55.10
Rate for Payer: BCBS MT Traditional	$58.00
Rate for Payer: Cash Price	$52.20
Rate for Payer: Cigna Commercial	$55.10
Rate for Payer: Cigna Medicare	$52.20
Rate for Payer: Medicaid All Medicaid	$53.36
Rate for Payer: Medicare All Medicare	$40.60
Rate for Payer: Monida Allegiance	$55.10
Rate for Payer: Monida First Choice Health	$56.26
Rate for Payer: Monida Montana Health Co-op	$55.10
Rate for Payer: Monida PacificSource	$55.10

Know your out-of-pocket cost for care.

All Charges