Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

FERRITIN (004598)

Facility

$58.00

Service Code	CPT 82728
Hospital Charge Code	4082728
Hospital Revenue Code	301
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

FERRITIN ASSAY

Facility

$144.00

Hospital Charge Code	90197104
Hospital Revenue Code	270
Min. Negotiated Rate	$100.80
Max. Negotiated Rate	$144.00
Rate for Payer: Aetna Commercial	$136.80
Rate for Payer: Aetna Medicare	$129.60
Rate for Payer: BCBS MT CHIP	$129.60
Rate for Payer: BCBS MT Closed Plan Network	$136.80
Rate for Payer: BCBS MT HealthLink	$129.60
Rate for Payer: BCBS MT Medicare	$129.60
Rate for Payer: BCBS MT POS	$136.80
Rate for Payer: BCBS MT Traditional	$144.00
Rate for Payer: Cash Price	$129.60
Rate for Payer: Cigna Commercial	$136.80
Rate for Payer: Cigna Medicare	$129.60
Rate for Payer: Medicaid All Medicaid	$132.48
Rate for Payer: Medicare All Medicare	$100.80
Rate for Payer: Monida Allegiance	$136.80
Rate for Payer: Monida First Choice Health	$139.68
Rate for Payer: Monida Montana Health Co-op	$136.80
Rate for Payer: Monida PacificSource	$136.80

FERRITIN ASSAY

Facility

$144.00

Hospital Charge Code	90197104
Hospital Revenue Code	270
Min. Negotiated Rate	$100.80
Max. Negotiated Rate	$144.00
Rate for Payer: Aetna Commercial	$136.80
Rate for Payer: Aetna Medicare	$129.60
Rate for Payer: BCBS MT CHIP	$129.60
Rate for Payer: BCBS MT Closed Plan Network	$136.80
Rate for Payer: BCBS MT HealthLink	$129.60
Rate for Payer: BCBS MT Medicare	$129.60
Rate for Payer: BCBS MT POS	$136.80
Rate for Payer: BCBS MT Traditional	$144.00
Rate for Payer: Cash Price	$129.60
Rate for Payer: Cigna Commercial	$136.80
Rate for Payer: Cigna Medicare	$129.60
Rate for Payer: Medicaid All Medicaid	$132.48
Rate for Payer: Medicare All Medicare	$100.80
Rate for Payer: Monida Allegiance	$136.80
Rate for Payer: Monida First Choice Health	$139.68
Rate for Payer: Monida Montana Health Co-op	$136.80
Rate for Payer: Monida PacificSource	$136.80

FERROUS SULFATE TAB [325 MG]

Facility

$8.00

Service Code	HCPCS A9150
Hospital Charge Code	3000178
Hospital Revenue Code	250
Min. Negotiated Rate	$5.60
Max. Negotiated Rate	$8.00
Rate for Payer: Aetna Commercial	$7.60
Rate for Payer: Aetna Medicare	$7.20
Rate for Payer: BCBS MT CHIP	$7.20
Rate for Payer: BCBS MT Closed Plan Network	$7.60
Rate for Payer: BCBS MT HealthLink	$7.20
Rate for Payer: BCBS MT Medicare	$7.20
Rate for Payer: BCBS MT POS	$7.60
Rate for Payer: BCBS MT Traditional	$8.00
Rate for Payer: Cash Price	$7.20
Rate for Payer: Cigna Commercial	$7.60
Rate for Payer: Cigna Medicare	$7.20
Rate for Payer: Medicaid All Medicaid	$7.36
Rate for Payer: Medicare All Medicare	$5.60
Rate for Payer: Monida Allegiance	$7.60
Rate for Payer: Monida First Choice Health	$7.76
Rate for Payer: Monida Montana Health Co-op	$7.60
Rate for Payer: Monida PacificSource	$7.60

FERROUS SULFATE TAB [325 MG]

Facility

$8.00

Service Code	HCPCS A9150
Hospital Charge Code	3000178
Hospital Revenue Code	250
Min. Negotiated Rate	$5.60
Max. Negotiated Rate	$8.00
Rate for Payer: Aetna Commercial	$7.60
Rate for Payer: Aetna Medicare	$7.20
Rate for Payer: BCBS MT CHIP	$7.20
Rate for Payer: BCBS MT Closed Plan Network	$7.60
Rate for Payer: BCBS MT HealthLink	$7.20
Rate for Payer: BCBS MT Medicare	$7.20
Rate for Payer: BCBS MT POS	$7.60
Rate for Payer: BCBS MT Traditional	$8.00
Rate for Payer: Cash Price	$7.20
Rate for Payer: Cigna Commercial	$7.60
Rate for Payer: Cigna Medicare	$7.20
Rate for Payer: Medicaid All Medicaid	$7.36
Rate for Payer: Medicare All Medicare	$5.60
Rate for Payer: Monida Allegiance	$7.60
Rate for Payer: Monida First Choice Health	$7.76
Rate for Payer: Monida Montana Health Co-op	$7.60
Rate for Payer: Monida PacificSource	$7.60

FIBRINOGEN (001610)

Facility

$69.00

Service Code	CPT 85384
Hospital Charge Code	4085384
Hospital Revenue Code	300
Min. Negotiated Rate	$48.30
Max. Negotiated Rate	$69.00
Rate for Payer: Aetna Commercial	$65.55
Rate for Payer: Aetna Medicare	$62.10
Rate for Payer: BCBS MT CHIP	$62.10
Rate for Payer: BCBS MT Closed Plan Network	$65.55
Rate for Payer: BCBS MT HealthLink	$62.10
Rate for Payer: BCBS MT Medicare	$62.10
Rate for Payer: BCBS MT POS	$65.55
Rate for Payer: BCBS MT Traditional	$69.00
Rate for Payer: Cash Price	$62.10
Rate for Payer: Cigna Commercial	$65.55
Rate for Payer: Cigna Medicare	$62.10
Rate for Payer: Medicaid All Medicaid	$63.48
Rate for Payer: Medicare All Medicare	$48.30
Rate for Payer: Monida Allegiance	$65.55
Rate for Payer: Monida First Choice Health	$66.93
Rate for Payer: Monida Montana Health Co-op	$65.55
Rate for Payer: Monida PacificSource	$65.55

FIBRINOGEN (001610)

Facility

$69.00

Service Code	CPT 85384
Hospital Charge Code	4085384
Hospital Revenue Code	300
Min. Negotiated Rate	$48.30
Max. Negotiated Rate	$69.00
Rate for Payer: Aetna Commercial	$65.55
Rate for Payer: Aetna Medicare	$62.10
Rate for Payer: BCBS MT CHIP	$62.10
Rate for Payer: BCBS MT Closed Plan Network	$65.55
Rate for Payer: BCBS MT HealthLink	$62.10
Rate for Payer: BCBS MT Medicare	$62.10
Rate for Payer: BCBS MT POS	$65.55
Rate for Payer: BCBS MT Traditional	$69.00
Rate for Payer: Cash Price	$62.10
Rate for Payer: Cigna Commercial	$65.55
Rate for Payer: Cigna Medicare	$62.10
Rate for Payer: Medicaid All Medicaid	$63.48
Rate for Payer: Medicare All Medicare	$48.30
Rate for Payer: Monida Allegiance	$65.55
Rate for Payer: Monida First Choice Health	$66.93
Rate for Payer: Monida Montana Health Co-op	$65.55
Rate for Payer: Monida PacificSource	$65.55

FIBROTEST ACTITEST

Facility

$425.00

Service Code	CPT 81596
Hospital Charge Code	4087985
Hospital Revenue Code	302
Min. Negotiated Rate	$297.50
Max. Negotiated Rate	$425.00
Rate for Payer: Aetna Commercial	$403.75
Rate for Payer: Aetna Medicare	$382.50
Rate for Payer: BCBS MT CHIP	$382.50
Rate for Payer: BCBS MT Closed Plan Network	$403.75
Rate for Payer: BCBS MT HealthLink	$382.50
Rate for Payer: BCBS MT Medicare	$382.50
Rate for Payer: BCBS MT POS	$403.75
Rate for Payer: BCBS MT Traditional	$425.00
Rate for Payer: Cash Price	$382.50
Rate for Payer: Cigna Commercial	$403.75
Rate for Payer: Cigna Medicare	$382.50
Rate for Payer: Medicaid All Medicaid	$391.00
Rate for Payer: Medicare All Medicare	$297.50
Rate for Payer: Monida Allegiance	$403.75
Rate for Payer: Monida First Choice Health	$412.25
Rate for Payer: Monida Montana Health Co-op	$403.75
Rate for Payer: Monida PacificSource	$403.75

FIBROTEST ACTITEST

Facility

$425.00

Service Code	CPT 81596
Hospital Charge Code	4087985
Hospital Revenue Code	302
Min. Negotiated Rate	$297.50
Max. Negotiated Rate	$425.00
Rate for Payer: Aetna Commercial	$403.75
Rate for Payer: Aetna Medicare	$382.50
Rate for Payer: BCBS MT CHIP	$382.50
Rate for Payer: BCBS MT Closed Plan Network	$403.75
Rate for Payer: BCBS MT HealthLink	$382.50
Rate for Payer: BCBS MT Medicare	$382.50
Rate for Payer: BCBS MT POS	$403.75
Rate for Payer: BCBS MT Traditional	$425.00
Rate for Payer: Cash Price	$382.50
Rate for Payer: Cigna Commercial	$403.75
Rate for Payer: Cigna Medicare	$382.50
Rate for Payer: Medicaid All Medicaid	$391.00
Rate for Payer: Medicare All Medicare	$297.50
Rate for Payer: Monida Allegiance	$403.75
Rate for Payer: Monida First Choice Health	$412.25
Rate for Payer: Monida Montana Health Co-op	$403.75
Rate for Payer: Monida PacificSource	$403.75

FILGRASTIM INJ [300 MCG/0.5 ML] SPEC ORD

Facility

$611.00

Service Code	HCPCS Q5125
Hospital Charge Code	3000179
Hospital Revenue Code	636
Min. Negotiated Rate	$427.70
Max. Negotiated Rate	$611.00
Rate for Payer: Aetna Commercial	$580.45
Rate for Payer: Aetna Medicare	$549.90
Rate for Payer: BCBS MT CHIP	$549.90
Rate for Payer: BCBS MT Closed Plan Network	$580.45
Rate for Payer: BCBS MT HealthLink	$549.90
Rate for Payer: BCBS MT Medicare	$549.90
Rate for Payer: BCBS MT POS	$580.45
Rate for Payer: BCBS MT Traditional	$611.00
Rate for Payer: Cash Price	$549.90
Rate for Payer: Cigna Commercial	$580.45
Rate for Payer: Cigna Medicare	$549.90
Rate for Payer: Medicaid All Medicaid	$562.12
Rate for Payer: Medicare All Medicare	$427.70
Rate for Payer: Monida Allegiance	$580.45
Rate for Payer: Monida First Choice Health	$592.67
Rate for Payer: Monida Montana Health Co-op	$580.45
Rate for Payer: Monida PacificSource	$580.45

FILGRASTIM INJ [300 MCG/0.5 ML] SPEC ORD

Facility

$611.00

Service Code	HCPCS Q5125
Hospital Charge Code	3000179
Hospital Revenue Code	636
Min. Negotiated Rate	$427.70
Max. Negotiated Rate	$611.00
Rate for Payer: Aetna Commercial	$580.45
Rate for Payer: Aetna Medicare	$549.90
Rate for Payer: BCBS MT CHIP	$549.90
Rate for Payer: BCBS MT Closed Plan Network	$580.45
Rate for Payer: BCBS MT HealthLink	$549.90
Rate for Payer: BCBS MT Medicare	$549.90
Rate for Payer: BCBS MT POS	$580.45
Rate for Payer: BCBS MT Traditional	$611.00
Rate for Payer: Cash Price	$549.90
Rate for Payer: Cigna Commercial	$580.45
Rate for Payer: Cigna Medicare	$549.90
Rate for Payer: Medicaid All Medicaid	$562.12
Rate for Payer: Medicare All Medicare	$427.70
Rate for Payer: Monida Allegiance	$580.45
Rate for Payer: Monida First Choice Health	$592.67
Rate for Payer: Monida Montana Health Co-op	$580.45
Rate for Payer: Monida PacificSource	$580.45

FILGRASTIM INJ [480 MCG/0.8 ML]

Facility

$893.00

Service Code	HCPCS J1442
Hospital Charge Code	3000580
Hospital Revenue Code	636
Min. Negotiated Rate	$625.10
Max. Negotiated Rate	$893.00
Rate for Payer: Aetna Commercial	$848.35
Rate for Payer: Aetna Medicare	$803.70
Rate for Payer: BCBS MT CHIP	$803.70
Rate for Payer: BCBS MT Closed Plan Network	$848.35
Rate for Payer: BCBS MT HealthLink	$803.70
Rate for Payer: BCBS MT Medicare	$803.70
Rate for Payer: BCBS MT POS	$848.35
Rate for Payer: BCBS MT Traditional	$893.00
Rate for Payer: Cash Price	$803.70
Rate for Payer: Cigna Commercial	$848.35
Rate for Payer: Cigna Medicare	$803.70
Rate for Payer: Medicaid All Medicaid	$821.56
Rate for Payer: Medicare All Medicare	$625.10
Rate for Payer: Monida Allegiance	$848.35
Rate for Payer: Monida First Choice Health	$866.21
Rate for Payer: Monida Montana Health Co-op	$848.35
Rate for Payer: Monida PacificSource	$848.35

FILGRASTIM INJ [480 MCG/0.8 ML]

Facility

$893.00

Service Code	HCPCS J1442
Hospital Charge Code	3000580
Hospital Revenue Code	636
Min. Negotiated Rate	$625.10
Max. Negotiated Rate	$893.00
Rate for Payer: Aetna Commercial	$848.35
Rate for Payer: Aetna Medicare	$803.70
Rate for Payer: BCBS MT CHIP	$803.70
Rate for Payer: BCBS MT Closed Plan Network	$848.35
Rate for Payer: BCBS MT HealthLink	$803.70
Rate for Payer: BCBS MT Medicare	$803.70
Rate for Payer: BCBS MT POS	$848.35
Rate for Payer: BCBS MT Traditional	$893.00
Rate for Payer: Cash Price	$803.70
Rate for Payer: Cigna Commercial	$848.35
Rate for Payer: Cigna Medicare	$803.70
Rate for Payer: Medicaid All Medicaid	$821.56
Rate for Payer: Medicare All Medicare	$625.10
Rate for Payer: Monida Allegiance	$848.35
Rate for Payer: Monida First Choice Health	$866.21
Rate for Payer: Monida Montana Health Co-op	$848.35
Rate for Payer: Monida PacificSource	$848.35

FILGRASTIM INJ [480 MCG/0.8 ML] PFS

Facility

$893.00

Service Code	HCPCS J1447
Hospital Charge Code	3000575
Hospital Revenue Code	636
Min. Negotiated Rate	$625.10
Max. Negotiated Rate	$893.00
Rate for Payer: Aetna Commercial	$848.35
Rate for Payer: Aetna Medicare	$803.70
Rate for Payer: BCBS MT CHIP	$803.70
Rate for Payer: BCBS MT Closed Plan Network	$848.35
Rate for Payer: BCBS MT HealthLink	$803.70
Rate for Payer: BCBS MT Medicare	$803.70
Rate for Payer: BCBS MT POS	$848.35
Rate for Payer: BCBS MT Traditional	$893.00
Rate for Payer: Cash Price	$803.70
Rate for Payer: Cigna Commercial	$848.35
Rate for Payer: Cigna Medicare	$803.70
Rate for Payer: Medicaid All Medicaid	$821.56
Rate for Payer: Medicare All Medicare	$625.10
Rate for Payer: Monida Allegiance	$848.35
Rate for Payer: Monida First Choice Health	$866.21
Rate for Payer: Monida Montana Health Co-op	$848.35
Rate for Payer: Monida PacificSource	$848.35

FILGRASTIM INJ [480 MCG/0.8 ML] PFS

Facility

$893.00

Service Code	HCPCS J1447
Hospital Charge Code	3000575
Hospital Revenue Code	636
Min. Negotiated Rate	$625.10
Max. Negotiated Rate	$893.00
Rate for Payer: Aetna Commercial	$848.35
Rate for Payer: Aetna Medicare	$803.70
Rate for Payer: BCBS MT CHIP	$803.70
Rate for Payer: BCBS MT Closed Plan Network	$848.35
Rate for Payer: BCBS MT HealthLink	$803.70
Rate for Payer: BCBS MT Medicare	$803.70
Rate for Payer: BCBS MT POS	$848.35
Rate for Payer: BCBS MT Traditional	$893.00
Rate for Payer: Cash Price	$803.70
Rate for Payer: Cigna Commercial	$848.35
Rate for Payer: Cigna Medicare	$803.70
Rate for Payer: Medicaid All Medicaid	$821.56
Rate for Payer: Medicare All Medicare	$625.10
Rate for Payer: Monida Allegiance	$848.35
Rate for Payer: Monida First Choice Health	$866.21
Rate for Payer: Monida Montana Health Co-op	$848.35
Rate for Payer: Monida PacificSource	$848.35

FINASTERIDE TAB [5 MG]

Facility

$8.00

Service Code	HCPCS J8499
Hospital Charge Code	3000180
Hospital Revenue Code	250
Min. Negotiated Rate	$5.60
Max. Negotiated Rate	$8.00
Rate for Payer: Aetna Commercial	$7.60
Rate for Payer: Aetna Medicare	$7.20
Rate for Payer: BCBS MT CHIP	$7.20
Rate for Payer: BCBS MT Closed Plan Network	$7.60
Rate for Payer: BCBS MT HealthLink	$7.20
Rate for Payer: BCBS MT Medicare	$7.20
Rate for Payer: BCBS MT POS	$7.60
Rate for Payer: BCBS MT Traditional	$8.00
Rate for Payer: Cash Price	$7.20
Rate for Payer: Cigna Commercial	$7.60
Rate for Payer: Cigna Medicare	$7.20
Rate for Payer: Medicaid All Medicaid	$7.36
Rate for Payer: Medicare All Medicare	$5.60
Rate for Payer: Monida Allegiance	$7.60
Rate for Payer: Monida First Choice Health	$7.76
Rate for Payer: Monida Montana Health Co-op	$7.60
Rate for Payer: Monida PacificSource	$7.60

FINASTERIDE TAB [5 MG]

Facility

$8.00

Service Code	HCPCS J8499
Hospital Charge Code	3000180
Hospital Revenue Code	250
Min. Negotiated Rate	$5.60
Max. Negotiated Rate	$8.00
Rate for Payer: Aetna Commercial	$7.60
Rate for Payer: Aetna Medicare	$7.20
Rate for Payer: BCBS MT CHIP	$7.20
Rate for Payer: BCBS MT Closed Plan Network	$7.60
Rate for Payer: BCBS MT HealthLink	$7.20
Rate for Payer: BCBS MT Medicare	$7.20
Rate for Payer: BCBS MT POS	$7.60
Rate for Payer: BCBS MT Traditional	$8.00
Rate for Payer: Cash Price	$7.20
Rate for Payer: Cigna Commercial	$7.60
Rate for Payer: Cigna Medicare	$7.20
Rate for Payer: Medicaid All Medicaid	$7.36
Rate for Payer: Medicare All Medicare	$5.60
Rate for Payer: Monida Allegiance	$7.60
Rate for Payer: Monida First Choice Health	$7.76
Rate for Payer: Monida Montana Health Co-op	$7.60
Rate for Payer: Monida PacificSource	$7.60

FINGER GUARDS ASST'D SIZES

Facility

$20.00

Service Code	HCPCS A4570
Hospital Charge Code	80030427
Hospital Revenue Code	270
Min. Negotiated Rate	$14.00
Max. Negotiated Rate	$20.00
Rate for Payer: Aetna Commercial	$19.00
Rate for Payer: Aetna Medicare	$18.00
Rate for Payer: BCBS MT CHIP	$18.00
Rate for Payer: BCBS MT Closed Plan Network	$19.00
Rate for Payer: BCBS MT HealthLink	$18.00
Rate for Payer: BCBS MT Medicare	$18.00
Rate for Payer: BCBS MT POS	$19.00
Rate for Payer: BCBS MT Traditional	$20.00
Rate for Payer: Cash Price	$18.00
Rate for Payer: Cigna Commercial	$19.00
Rate for Payer: Cigna Medicare	$18.00
Rate for Payer: Medicaid All Medicaid	$18.40
Rate for Payer: Medicare All Medicare	$14.00
Rate for Payer: Monida Allegiance	$19.00
Rate for Payer: Monida First Choice Health	$19.40
Rate for Payer: Monida Montana Health Co-op	$19.00
Rate for Payer: Monida PacificSource	$19.00

FINGER GUARDS ASST'D SIZES

Facility

$20.00

Service Code	HCPCS A4570
Hospital Charge Code	80030427
Hospital Revenue Code	270
Min. Negotiated Rate	$14.00
Max. Negotiated Rate	$20.00
Rate for Payer: Aetna Commercial	$19.00
Rate for Payer: Aetna Medicare	$18.00
Rate for Payer: BCBS MT CHIP	$18.00
Rate for Payer: BCBS MT Closed Plan Network	$19.00
Rate for Payer: BCBS MT HealthLink	$18.00
Rate for Payer: BCBS MT Medicare	$18.00
Rate for Payer: BCBS MT POS	$19.00
Rate for Payer: BCBS MT Traditional	$20.00
Rate for Payer: Cash Price	$18.00
Rate for Payer: Cigna Commercial	$19.00
Rate for Payer: Cigna Medicare	$18.00
Rate for Payer: Medicaid All Medicaid	$18.40
Rate for Payer: Medicare All Medicare	$14.00
Rate for Payer: Monida Allegiance	$19.00
Rate for Payer: Monida First Choice Health	$19.40
Rate for Payer: Monida Montana Health Co-op	$19.00
Rate for Payer: Monida PacificSource	$19.00

FINGER SPLINT SAM

Facility

$89.00

Service Code	HCPCS A4570
Hospital Charge Code	80020008
Hospital Revenue Code	270
Min. Negotiated Rate	$62.30
Max. Negotiated Rate	$89.00
Rate for Payer: Aetna Commercial	$84.55
Rate for Payer: Aetna Medicare	$80.10
Rate for Payer: BCBS MT CHIP	$80.10
Rate for Payer: BCBS MT Closed Plan Network	$84.55
Rate for Payer: BCBS MT HealthLink	$80.10
Rate for Payer: BCBS MT Medicare	$80.10
Rate for Payer: BCBS MT POS	$84.55
Rate for Payer: BCBS MT Traditional	$89.00
Rate for Payer: Cash Price	$80.10
Rate for Payer: Cigna Commercial	$84.55
Rate for Payer: Cigna Medicare	$80.10
Rate for Payer: Medicaid All Medicaid	$81.88
Rate for Payer: Medicare All Medicare	$62.30
Rate for Payer: Monida Allegiance	$84.55
Rate for Payer: Monida First Choice Health	$86.33
Rate for Payer: Monida Montana Health Co-op	$84.55
Rate for Payer: Monida PacificSource	$84.55

FINGER SPLINT SAM

Facility

$89.00

Service Code	HCPCS A4570
Hospital Charge Code	80020008
Hospital Revenue Code	270
Min. Negotiated Rate	$62.30
Max. Negotiated Rate	$89.00
Rate for Payer: Aetna Commercial	$84.55
Rate for Payer: Aetna Medicare	$80.10
Rate for Payer: BCBS MT CHIP	$80.10
Rate for Payer: BCBS MT Closed Plan Network	$84.55
Rate for Payer: BCBS MT HealthLink	$80.10
Rate for Payer: BCBS MT Medicare	$80.10
Rate for Payer: BCBS MT POS	$84.55
Rate for Payer: BCBS MT Traditional	$89.00
Rate for Payer: Cash Price	$80.10
Rate for Payer: Cigna Commercial	$84.55
Rate for Payer: Cigna Medicare	$80.10
Rate for Payer: Medicaid All Medicaid	$81.88
Rate for Payer: Medicare All Medicare	$62.30
Rate for Payer: Monida Allegiance	$84.55
Rate for Payer: Monida First Choice Health	$86.33
Rate for Payer: Monida Montana Health Co-op	$84.55
Rate for Payer: Monida PacificSource	$84.55

FINGER SPLINT, STATIC

Facility

$23.00

Service Code	HCPCS Q4049
Hospital Charge Code	8004049
Hospital Revenue Code	290
Min. Negotiated Rate	$16.10
Max. Negotiated Rate	$23.00
Rate for Payer: Aetna Commercial	$21.85
Rate for Payer: Aetna Medicare	$20.70
Rate for Payer: BCBS MT CHIP	$20.70
Rate for Payer: BCBS MT Closed Plan Network	$21.85
Rate for Payer: BCBS MT HealthLink	$20.70
Rate for Payer: BCBS MT Medicare	$20.70
Rate for Payer: BCBS MT POS	$21.85
Rate for Payer: BCBS MT Traditional	$23.00
Rate for Payer: Cash Price	$20.70
Rate for Payer: Cigna Commercial	$21.85
Rate for Payer: Cigna Medicare	$20.70
Rate for Payer: Medicaid All Medicaid	$21.16
Rate for Payer: Medicare All Medicare	$16.10
Rate for Payer: Monida Allegiance	$21.85
Rate for Payer: Monida First Choice Health	$22.31
Rate for Payer: Monida Montana Health Co-op	$21.85
Rate for Payer: Monida PacificSource	$21.85

FINGER SPLINT, STATIC

Facility

$23.00

Service Code	HCPCS Q4049
Hospital Charge Code	8004049
Hospital Revenue Code	290
Min. Negotiated Rate	$16.10
Max. Negotiated Rate	$23.00
Rate for Payer: Aetna Commercial	$21.85
Rate for Payer: Aetna Medicare	$20.70
Rate for Payer: BCBS MT CHIP	$20.70
Rate for Payer: BCBS MT Closed Plan Network	$21.85
Rate for Payer: BCBS MT HealthLink	$20.70
Rate for Payer: BCBS MT Medicare	$20.70
Rate for Payer: BCBS MT POS	$21.85
Rate for Payer: BCBS MT Traditional	$23.00
Rate for Payer: Cash Price	$20.70
Rate for Payer: Cigna Commercial	$21.85
Rate for Payer: Cigna Medicare	$20.70
Rate for Payer: Medicaid All Medicaid	$21.16
Rate for Payer: Medicare All Medicare	$16.10
Rate for Payer: Monida Allegiance	$21.85
Rate for Payer: Monida First Choice Health	$22.31
Rate for Payer: Monida Montana Health Co-op	$21.85
Rate for Payer: Monida PacificSource	$21.85

FISHER SUREVUE RPR

Facility

$93.39

Hospital Charge Code	90197069
Hospital Revenue Code	270
Min. Negotiated Rate	$65.37
Max. Negotiated Rate	$93.39
Rate for Payer: Aetna Commercial	$88.72
Rate for Payer: Aetna Medicare	$84.05
Rate for Payer: BCBS MT CHIP	$84.05
Rate for Payer: BCBS MT Closed Plan Network	$88.72
Rate for Payer: BCBS MT HealthLink	$84.05
Rate for Payer: BCBS MT Medicare	$84.05
Rate for Payer: BCBS MT POS	$88.72
Rate for Payer: BCBS MT Traditional	$93.39
Rate for Payer: Cash Price	$84.05
Rate for Payer: Cigna Commercial	$88.72
Rate for Payer: Cigna Medicare	$84.05
Rate for Payer: Medicaid All Medicaid	$85.92
Rate for Payer: Medicare All Medicare	$65.37
Rate for Payer: Monida Allegiance	$88.72
Rate for Payer: Monida First Choice Health	$90.59
Rate for Payer: Monida Montana Health Co-op	$88.72
Rate for Payer: Monida PacificSource	$88.72

FISHER SUREVUE RPR

Facility

$93.39

Hospital Charge Code	90197069
Hospital Revenue Code	270
Min. Negotiated Rate	$65.37
Max. Negotiated Rate	$93.39
Rate for Payer: Aetna Commercial	$88.72
Rate for Payer: Aetna Medicare	$84.05
Rate for Payer: BCBS MT CHIP	$84.05
Rate for Payer: BCBS MT Closed Plan Network	$88.72
Rate for Payer: BCBS MT HealthLink	$84.05
Rate for Payer: BCBS MT Medicare	$84.05
Rate for Payer: BCBS MT POS	$88.72
Rate for Payer: BCBS MT Traditional	$93.39
Rate for Payer: Cash Price	$84.05
Rate for Payer: Cigna Commercial	$88.72
Rate for Payer: Cigna Medicare	$84.05
Rate for Payer: Medicaid All Medicaid	$85.92
Rate for Payer: Medicare All Medicare	$65.37
Rate for Payer: Monida Allegiance	$88.72
Rate for Payer: Monida First Choice Health	$90.59
Rate for Payer: Monida Montana Health Co-op	$88.72
Rate for Payer: Monida PacificSource	$88.72

Know your out-of-pocket cost for care.

All Charges