Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

AMYLASE

Facility

$111.00

Service Code	HCPCS 82150
Hospital Charge Code	4082150
Hospital Revenue Code	301
Min. Negotiated Rate	$77.70
Max. Negotiated Rate	$111.00
Rate for Payer: Aetna Commercial	$105.45
Rate for Payer: Aetna Medicare	$99.90
Rate for Payer: BCBS MT CHIP	$99.90
Rate for Payer: BCBS MT Closed Plan Network	$105.45
Rate for Payer: BCBS MT HealthLink	$99.90
Rate for Payer: BCBS MT Medicare	$99.90
Rate for Payer: BCBS MT POS	$105.45
Rate for Payer: BCBS MT Traditional	$111.00
Rate for Payer: Cash Price	$99.90
Rate for Payer: Cigna Commercial	$105.45
Rate for Payer: Cigna Medicare	$99.90
Rate for Payer: Medicaid All Medicaid	$102.12
Rate for Payer: Medicare All Medicare	$77.70
Rate for Payer: Monida Allegiance	$105.45
Rate for Payer: Monida First Choice Health	$107.67
Rate for Payer: Monida Montana Health Co-op	$105.45
Rate for Payer: Monida PacificSource	$105.45

AMYLASE

Facility

$111.00

Service Code	HCPCS 82150
Hospital Charge Code	4082150
Hospital Revenue Code	301
Min. Negotiated Rate	$77.70
Max. Negotiated Rate	$111.00
Rate for Payer: Aetna Commercial	$105.45
Rate for Payer: Aetna Medicare	$99.90
Rate for Payer: BCBS MT CHIP	$99.90
Rate for Payer: BCBS MT Closed Plan Network	$105.45
Rate for Payer: BCBS MT HealthLink	$99.90
Rate for Payer: BCBS MT Medicare	$99.90
Rate for Payer: BCBS MT POS	$105.45
Rate for Payer: BCBS MT Traditional	$111.00
Rate for Payer: Cash Price	$99.90
Rate for Payer: Cigna Commercial	$105.45
Rate for Payer: Cigna Medicare	$99.90
Rate for Payer: Medicaid All Medicaid	$102.12
Rate for Payer: Medicare All Medicare	$77.70
Rate for Payer: Monida Allegiance	$105.45
Rate for Payer: Monida First Choice Health	$107.67
Rate for Payer: Monida Montana Health Co-op	$105.45
Rate for Payer: Monida PacificSource	$105.45

.ANAEROBIC CULTURE

Facility

$51.00

Service Code	HCPCS 87075
Hospital Charge Code	4087075
Hospital Revenue Code	306
Min. Negotiated Rate	$35.70
Max. Negotiated Rate	$51.00
Rate for Payer: Aetna Commercial	$48.45
Rate for Payer: Aetna Medicare	$45.90
Rate for Payer: BCBS MT CHIP	$45.90
Rate for Payer: BCBS MT Closed Plan Network	$48.45
Rate for Payer: BCBS MT HealthLink	$45.90
Rate for Payer: BCBS MT Medicare	$45.90
Rate for Payer: BCBS MT POS	$48.45
Rate for Payer: BCBS MT Traditional	$51.00
Rate for Payer: Cash Price	$45.90
Rate for Payer: Cigna Commercial	$48.45
Rate for Payer: Cigna Medicare	$45.90
Rate for Payer: Medicaid All Medicaid	$46.92
Rate for Payer: Medicare All Medicare	$35.70
Rate for Payer: Monida Allegiance	$48.45
Rate for Payer: Monida First Choice Health	$49.47
Rate for Payer: Monida Montana Health Co-op	$48.45
Rate for Payer: Monida PacificSource	$48.45

.ANAEROBIC CULTURE

Facility

$51.00

Service Code	HCPCS 87075
Hospital Charge Code	4087075
Hospital Revenue Code	306
Min. Negotiated Rate	$35.70
Max. Negotiated Rate	$51.00
Rate for Payer: Aetna Commercial	$48.45
Rate for Payer: Aetna Medicare	$45.90
Rate for Payer: BCBS MT CHIP	$45.90
Rate for Payer: BCBS MT Closed Plan Network	$48.45
Rate for Payer: BCBS MT HealthLink	$45.90
Rate for Payer: BCBS MT Medicare	$45.90
Rate for Payer: BCBS MT POS	$48.45
Rate for Payer: BCBS MT Traditional	$51.00
Rate for Payer: Cash Price	$45.90
Rate for Payer: Cigna Commercial	$48.45
Rate for Payer: Cigna Medicare	$45.90
Rate for Payer: Medicaid All Medicaid	$46.92
Rate for Payer: Medicare All Medicare	$35.70
Rate for Payer: Monida Allegiance	$48.45
Rate for Payer: Monida First Choice Health	$49.47
Rate for Payer: Monida Montana Health Co-op	$48.45
Rate for Payer: Monida PacificSource	$48.45

ANA, IFA (164947)

Facility

$39.00

Service Code	HCPCS 86038
Hospital Charge Code	4086039
Hospital Revenue Code	300
Min. Negotiated Rate	$27.30
Max. Negotiated Rate	$39.00
Rate for Payer: Aetna Commercial	$37.05
Rate for Payer: Aetna Medicare	$35.10
Rate for Payer: BCBS MT CHIP	$35.10
Rate for Payer: BCBS MT Closed Plan Network	$37.05
Rate for Payer: BCBS MT HealthLink	$35.10
Rate for Payer: BCBS MT Medicare	$35.10
Rate for Payer: BCBS MT POS	$37.05
Rate for Payer: BCBS MT Traditional	$39.00
Rate for Payer: Cash Price	$35.10
Rate for Payer: Cigna Commercial	$37.05
Rate for Payer: Cigna Medicare	$35.10
Rate for Payer: Medicaid All Medicaid	$35.88
Rate for Payer: Medicare All Medicare	$27.30
Rate for Payer: Monida Allegiance	$37.05
Rate for Payer: Monida First Choice Health	$37.83
Rate for Payer: Monida Montana Health Co-op	$37.05
Rate for Payer: Monida PacificSource	$37.05

ANA, IFA (164947)

Facility

$39.00

Service Code	HCPCS 86038
Hospital Charge Code	4086039
Hospital Revenue Code	300
Min. Negotiated Rate	$27.30
Max. Negotiated Rate	$39.00
Rate for Payer: Aetna Commercial	$37.05
Rate for Payer: Aetna Medicare	$35.10
Rate for Payer: BCBS MT CHIP	$35.10
Rate for Payer: BCBS MT Closed Plan Network	$37.05
Rate for Payer: BCBS MT HealthLink	$35.10
Rate for Payer: BCBS MT Medicare	$35.10
Rate for Payer: BCBS MT POS	$37.05
Rate for Payer: BCBS MT Traditional	$39.00
Rate for Payer: Cash Price	$35.10
Rate for Payer: Cigna Commercial	$37.05
Rate for Payer: Cigna Medicare	$35.10
Rate for Payer: Medicaid All Medicaid	$35.88
Rate for Payer: Medicare All Medicare	$27.30
Rate for Payer: Monida Allegiance	$37.05
Rate for Payer: Monida First Choice Health	$37.83
Rate for Payer: Monida Montana Health Co-op	$37.05
Rate for Payer: Monida PacificSource	$37.05

ANA SCREEN WITH REFLEX (164863)

Facility

$39.00

Service Code	HCPCS 86038
Hospital Charge Code	4086038
Hospital Revenue Code	300
Min. Negotiated Rate	$27.30
Max. Negotiated Rate	$39.00
Rate for Payer: Aetna Commercial	$37.05
Rate for Payer: Aetna Medicare	$35.10
Rate for Payer: BCBS MT CHIP	$35.10
Rate for Payer: BCBS MT Closed Plan Network	$37.05
Rate for Payer: BCBS MT HealthLink	$35.10
Rate for Payer: BCBS MT Medicare	$35.10
Rate for Payer: BCBS MT POS	$37.05
Rate for Payer: BCBS MT Traditional	$39.00
Rate for Payer: Cash Price	$35.10
Rate for Payer: Cigna Commercial	$37.05
Rate for Payer: Cigna Medicare	$35.10
Rate for Payer: Medicaid All Medicaid	$35.88
Rate for Payer: Medicare All Medicare	$27.30
Rate for Payer: Monida Allegiance	$37.05
Rate for Payer: Monida First Choice Health	$37.83
Rate for Payer: Monida Montana Health Co-op	$37.05
Rate for Payer: Monida PacificSource	$37.05

ANA SCREEN WITH REFLEX (164863)

Facility

$39.00

Service Code	HCPCS 86038
Hospital Charge Code	4086038
Hospital Revenue Code	300
Min. Negotiated Rate	$27.30
Max. Negotiated Rate	$39.00
Rate for Payer: Aetna Commercial	$37.05
Rate for Payer: Aetna Medicare	$35.10
Rate for Payer: BCBS MT CHIP	$35.10
Rate for Payer: BCBS MT Closed Plan Network	$37.05
Rate for Payer: BCBS MT HealthLink	$35.10
Rate for Payer: BCBS MT Medicare	$35.10
Rate for Payer: BCBS MT POS	$37.05
Rate for Payer: BCBS MT Traditional	$39.00
Rate for Payer: Cash Price	$35.10
Rate for Payer: Cigna Commercial	$37.05
Rate for Payer: Cigna Medicare	$35.10
Rate for Payer: Medicaid All Medicaid	$35.88
Rate for Payer: Medicare All Medicare	$27.30
Rate for Payer: Monida Allegiance	$37.05
Rate for Payer: Monida First Choice Health	$37.83
Rate for Payer: Monida Montana Health Co-op	$37.05
Rate for Payer: Monida PacificSource	$37.05

ANCA W/ REFLEX (520090)

Facility

$218.00

Service Code	HCPCS 86036
Hospital Charge Code	4086036
Hospital Revenue Code	301
Min. Negotiated Rate	$152.60
Max. Negotiated Rate	$218.00
Rate for Payer: Aetna Commercial	$207.10
Rate for Payer: Aetna Medicare	$196.20
Rate for Payer: BCBS MT CHIP	$196.20
Rate for Payer: BCBS MT Closed Plan Network	$207.10
Rate for Payer: BCBS MT HealthLink	$196.20
Rate for Payer: BCBS MT Medicare	$196.20
Rate for Payer: BCBS MT POS	$207.10
Rate for Payer: BCBS MT Traditional	$218.00
Rate for Payer: Cash Price	$196.20
Rate for Payer: Cigna Commercial	$207.10
Rate for Payer: Cigna Medicare	$196.20
Rate for Payer: Medicaid All Medicaid	$200.56
Rate for Payer: Medicare All Medicare	$152.60
Rate for Payer: Monida Allegiance	$207.10
Rate for Payer: Monida First Choice Health	$211.46
Rate for Payer: Monida Montana Health Co-op	$207.10
Rate for Payer: Monida PacificSource	$207.10

ANCA W/ REFLEX (520090)

Facility

$218.00

Service Code	HCPCS 86036
Hospital Charge Code	4086036
Hospital Revenue Code	301
Min. Negotiated Rate	$152.60
Max. Negotiated Rate	$218.00
Rate for Payer: Aetna Commercial	$207.10
Rate for Payer: Aetna Medicare	$196.20
Rate for Payer: BCBS MT CHIP	$196.20
Rate for Payer: BCBS MT Closed Plan Network	$207.10
Rate for Payer: BCBS MT HealthLink	$196.20
Rate for Payer: BCBS MT Medicare	$196.20
Rate for Payer: BCBS MT POS	$207.10
Rate for Payer: BCBS MT Traditional	$218.00
Rate for Payer: Cash Price	$196.20
Rate for Payer: Cigna Commercial	$207.10
Rate for Payer: Cigna Medicare	$196.20
Rate for Payer: Medicaid All Medicaid	$200.56
Rate for Payer: Medicare All Medicare	$152.60
Rate for Payer: Monida Allegiance	$207.10
Rate for Payer: Monida First Choice Health	$211.46
Rate for Payer: Monida Montana Health Co-op	$207.10
Rate for Payer: Monida PacificSource	$207.10

ANESTHESIA COLONOSCOPY 00811

Facility

$515.00

Service Code	HCPCS 00811
Hospital Charge Code	5800811
Hospital Revenue Code	370
Min. Negotiated Rate	$360.50
Max. Negotiated Rate	$515.00
Rate for Payer: Aetna Commercial	$489.25
Rate for Payer: Aetna Medicare	$463.50
Rate for Payer: BCBS MT CHIP	$463.50
Rate for Payer: BCBS MT Closed Plan Network	$489.25
Rate for Payer: BCBS MT HealthLink	$463.50
Rate for Payer: BCBS MT Medicare	$463.50
Rate for Payer: BCBS MT POS	$489.25
Rate for Payer: BCBS MT Traditional	$515.00
Rate for Payer: Cash Price	$463.50
Rate for Payer: Cigna Commercial	$489.25
Rate for Payer: Cigna Medicare	$463.50
Rate for Payer: Medicaid All Medicaid	$473.80
Rate for Payer: Medicare All Medicare	$360.50
Rate for Payer: Monida Allegiance	$489.25
Rate for Payer: Monida First Choice Health	$499.55
Rate for Payer: Monida Montana Health Co-op	$489.25
Rate for Payer: Monida PacificSource	$489.25

ANESTHESIA COLONOSCOPY 00811

Facility

$515.00

Service Code	HCPCS 00811
Hospital Charge Code	5800811
Hospital Revenue Code	370
Min. Negotiated Rate	$360.50
Max. Negotiated Rate	$515.00
Rate for Payer: Aetna Commercial	$489.25
Rate for Payer: Aetna Medicare	$463.50
Rate for Payer: BCBS MT CHIP	$463.50
Rate for Payer: BCBS MT Closed Plan Network	$489.25
Rate for Payer: BCBS MT HealthLink	$463.50
Rate for Payer: BCBS MT Medicare	$463.50
Rate for Payer: BCBS MT POS	$489.25
Rate for Payer: BCBS MT Traditional	$515.00
Rate for Payer: Cash Price	$463.50
Rate for Payer: Cigna Commercial	$489.25
Rate for Payer: Cigna Medicare	$463.50
Rate for Payer: Medicaid All Medicaid	$473.80
Rate for Payer: Medicare All Medicare	$360.50
Rate for Payer: Monida Allegiance	$489.25
Rate for Payer: Monida First Choice Health	$499.55
Rate for Payer: Monida Montana Health Co-op	$489.25
Rate for Payer: Monida PacificSource	$489.25

ANESTHESIA ENDO 00812

Facility

$425.00

Service Code	HCPCS 00812
Hospital Charge Code	5800812
Hospital Revenue Code	370
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

ANESTHESIA ENDO 00812

Facility

$425.00

Service Code	HCPCS 00812
Hospital Charge Code	5800812
Hospital Revenue Code	370
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

ANGIOTENSIN CONVERTING ENZYME (010116)

Facility

$20.00

Service Code	HCPCS 82164
Hospital Charge Code	4082164
Hospital Revenue Code	300
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

ANGIOTENSIN CONVERTING ENZYME (010116)

Facility

$20.00

Service Code	HCPCS 82164
Hospital Charge Code	4082164
Hospital Revenue Code	300
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

ANKLE BRACE

Facility

$317.00

Service Code	HCPCS L1906
Hospital Charge Code	8001906
Hospital Revenue Code	290
Min. Negotiated Rate	$221.90
Max. Negotiated Rate	$317.00
Rate for Payer: Aetna Commercial	$301.15
Rate for Payer: Aetna Medicare	$285.30
Rate for Payer: BCBS MT CHIP	$285.30
Rate for Payer: BCBS MT Closed Plan Network	$301.15
Rate for Payer: BCBS MT HealthLink	$285.30
Rate for Payer: BCBS MT Medicare	$285.30
Rate for Payer: BCBS MT POS	$301.15
Rate for Payer: BCBS MT Traditional	$317.00
Rate for Payer: Cash Price	$285.30
Rate for Payer: Cigna Commercial	$301.15
Rate for Payer: Cigna Medicare	$285.30
Rate for Payer: Medicaid All Medicaid	$291.64
Rate for Payer: Medicare All Medicare	$221.90
Rate for Payer: Monida Allegiance	$301.15
Rate for Payer: Monida First Choice Health	$307.49
Rate for Payer: Monida Montana Health Co-op	$301.15
Rate for Payer: Monida PacificSource	$301.15

ANKLE BRACE

Facility

$317.00

Service Code	HCPCS L1906
Hospital Charge Code	8001906
Hospital Revenue Code	290
Min. Negotiated Rate	$221.90
Max. Negotiated Rate	$317.00
Rate for Payer: Aetna Commercial	$301.15
Rate for Payer: Aetna Medicare	$285.30
Rate for Payer: BCBS MT CHIP	$285.30
Rate for Payer: BCBS MT Closed Plan Network	$301.15
Rate for Payer: BCBS MT HealthLink	$285.30
Rate for Payer: BCBS MT Medicare	$285.30
Rate for Payer: BCBS MT POS	$301.15
Rate for Payer: BCBS MT Traditional	$317.00
Rate for Payer: Cash Price	$285.30
Rate for Payer: Cigna Commercial	$301.15
Rate for Payer: Cigna Medicare	$285.30
Rate for Payer: Medicaid All Medicaid	$291.64
Rate for Payer: Medicare All Medicare	$221.90
Rate for Payer: Monida Allegiance	$301.15
Rate for Payer: Monida First Choice Health	$307.49
Rate for Payer: Monida Montana Health Co-op	$301.15
Rate for Payer: Monida PacificSource	$301.15

ANKLE BRACE AIR GEL 9.0''

Facility

$46.00

Hospital Charge Code	2893172
Hospital Revenue Code	290
Min. Negotiated Rate	$32.20
Max. Negotiated Rate	$46.00
Rate for Payer: Aetna Commercial	$43.70
Rate for Payer: Aetna Medicare	$41.40
Rate for Payer: BCBS MT CHIP	$41.40
Rate for Payer: BCBS MT Closed Plan Network	$43.70
Rate for Payer: BCBS MT HealthLink	$41.40
Rate for Payer: BCBS MT Medicare	$41.40
Rate for Payer: BCBS MT POS	$43.70
Rate for Payer: BCBS MT Traditional	$46.00
Rate for Payer: Cash Price	$41.40
Rate for Payer: Cigna Commercial	$43.70
Rate for Payer: Cigna Medicare	$41.40
Rate for Payer: Medicaid All Medicaid	$42.32
Rate for Payer: Medicare All Medicare	$32.20
Rate for Payer: Monida Allegiance	$43.70
Rate for Payer: Monida First Choice Health	$44.62
Rate for Payer: Monida Montana Health Co-op	$43.70
Rate for Payer: Monida PacificSource	$43.70

ANKLE BRACE AIR GEL 9.0''

Facility

$46.00

Hospital Charge Code	2893172
Hospital Revenue Code	290
Min. Negotiated Rate	$32.20
Max. Negotiated Rate	$46.00
Rate for Payer: Aetna Commercial	$43.70
Rate for Payer: Aetna Medicare	$41.40
Rate for Payer: BCBS MT CHIP	$41.40
Rate for Payer: BCBS MT Closed Plan Network	$43.70
Rate for Payer: BCBS MT HealthLink	$41.40
Rate for Payer: BCBS MT Medicare	$41.40
Rate for Payer: BCBS MT POS	$43.70
Rate for Payer: BCBS MT Traditional	$46.00
Rate for Payer: Cash Price	$41.40
Rate for Payer: Cigna Commercial	$43.70
Rate for Payer: Cigna Medicare	$41.40
Rate for Payer: Medicaid All Medicaid	$42.32
Rate for Payer: Medicare All Medicare	$32.20
Rate for Payer: Monida Allegiance	$43.70
Rate for Payer: Monida First Choice Health	$44.62
Rate for Payer: Monida Montana Health Co-op	$43.70
Rate for Payer: Monida PacificSource	$43.70

ANKLE BRACE AIR GEL SM. 8.5

Facility

$57.00

Hospital Charge Code	2893151
Hospital Revenue Code	270
Min. Negotiated Rate	$39.90
Max. Negotiated Rate	$57.00
Rate for Payer: Aetna Commercial	$54.15
Rate for Payer: Aetna Medicare	$51.30
Rate for Payer: BCBS MT CHIP	$51.30
Rate for Payer: BCBS MT Closed Plan Network	$54.15
Rate for Payer: BCBS MT HealthLink	$51.30
Rate for Payer: BCBS MT Medicare	$51.30
Rate for Payer: BCBS MT POS	$54.15
Rate for Payer: BCBS MT Traditional	$57.00
Rate for Payer: Cash Price	$51.30
Rate for Payer: Cigna Commercial	$54.15
Rate for Payer: Cigna Medicare	$51.30
Rate for Payer: Medicaid All Medicaid	$52.44
Rate for Payer: Medicare All Medicare	$39.90
Rate for Payer: Monida Allegiance	$54.15
Rate for Payer: Monida First Choice Health	$55.29
Rate for Payer: Monida Montana Health Co-op	$54.15
Rate for Payer: Monida PacificSource	$54.15

ANKLE BRACE AIR GEL SM. 8.5

Facility

$57.00

Hospital Charge Code	2893151
Hospital Revenue Code	270
Min. Negotiated Rate	$39.90
Max. Negotiated Rate	$57.00
Rate for Payer: Aetna Commercial	$54.15
Rate for Payer: Aetna Medicare	$51.30
Rate for Payer: BCBS MT CHIP	$51.30
Rate for Payer: BCBS MT Closed Plan Network	$54.15
Rate for Payer: BCBS MT HealthLink	$51.30
Rate for Payer: BCBS MT Medicare	$51.30
Rate for Payer: BCBS MT POS	$54.15
Rate for Payer: BCBS MT Traditional	$57.00
Rate for Payer: Cash Price	$51.30
Rate for Payer: Cigna Commercial	$54.15
Rate for Payer: Cigna Medicare	$51.30
Rate for Payer: Medicaid All Medicaid	$52.44
Rate for Payer: Medicare All Medicare	$39.90
Rate for Payer: Monida Allegiance	$54.15
Rate for Payer: Monida First Choice Health	$55.29
Rate for Payer: Monida Montana Health Co-op	$54.15
Rate for Payer: Monida PacificSource	$54.15

ANKLE SPINT LACE-UP SM

Facility

$44.00

Hospital Charge Code	2820002
Hospital Revenue Code	270
Min. Negotiated Rate	$30.80
Max. Negotiated Rate	$44.00
Rate for Payer: Aetna Commercial	$41.80
Rate for Payer: Aetna Medicare	$39.60
Rate for Payer: BCBS MT CHIP	$39.60
Rate for Payer: BCBS MT Closed Plan Network	$41.80
Rate for Payer: BCBS MT HealthLink	$39.60
Rate for Payer: BCBS MT Medicare	$39.60
Rate for Payer: BCBS MT POS	$41.80
Rate for Payer: BCBS MT Traditional	$44.00
Rate for Payer: Cash Price	$39.60
Rate for Payer: Cigna Commercial	$41.80
Rate for Payer: Cigna Medicare	$39.60
Rate for Payer: Medicaid All Medicaid	$40.48
Rate for Payer: Medicare All Medicare	$30.80
Rate for Payer: Monida Allegiance	$41.80
Rate for Payer: Monida First Choice Health	$42.68
Rate for Payer: Monida Montana Health Co-op	$41.80
Rate for Payer: Monida PacificSource	$41.80

ANKLE SPINT LACE-UP SM

Facility

$44.00

Hospital Charge Code	2820002
Hospital Revenue Code	270
Min. Negotiated Rate	$30.80
Max. Negotiated Rate	$44.00
Rate for Payer: Aetna Commercial	$41.80
Rate for Payer: Aetna Medicare	$39.60
Rate for Payer: BCBS MT CHIP	$39.60
Rate for Payer: BCBS MT Closed Plan Network	$41.80
Rate for Payer: BCBS MT HealthLink	$39.60
Rate for Payer: BCBS MT Medicare	$39.60
Rate for Payer: BCBS MT POS	$41.80
Rate for Payer: BCBS MT Traditional	$44.00
Rate for Payer: Cash Price	$39.60
Rate for Payer: Cigna Commercial	$41.80
Rate for Payer: Cigna Medicare	$39.60
Rate for Payer: Medicaid All Medicaid	$40.48
Rate for Payer: Medicare All Medicare	$30.80
Rate for Payer: Monida Allegiance	$41.80
Rate for Payer: Monida First Choice Health	$42.68
Rate for Payer: Monida Montana Health Co-op	$41.80
Rate for Payer: Monida PacificSource	$41.80

ANKLE SPLINT LACE-UP LG

Facility

$36.00

Service Code	HCPCS E1815
Hospital Charge Code	2893174
Hospital Revenue Code	290
Min. Negotiated Rate	$25.20
Max. Negotiated Rate	$36.00
Rate for Payer: Aetna Commercial	$34.20
Rate for Payer: Aetna Medicare	$32.40
Rate for Payer: BCBS MT CHIP	$32.40
Rate for Payer: BCBS MT Closed Plan Network	$34.20
Rate for Payer: BCBS MT HealthLink	$32.40
Rate for Payer: BCBS MT Medicare	$32.40
Rate for Payer: BCBS MT POS	$34.20
Rate for Payer: BCBS MT Traditional	$36.00
Rate for Payer: Cash Price	$32.40
Rate for Payer: Cigna Commercial	$34.20
Rate for Payer: Cigna Medicare	$32.40
Rate for Payer: Medicaid All Medicaid	$33.12
Rate for Payer: Medicare All Medicare	$25.20
Rate for Payer: Monida Allegiance	$34.20
Rate for Payer: Monida First Choice Health	$34.92
Rate for Payer: Monida Montana Health Co-op	$34.20
Rate for Payer: Monida PacificSource	$34.20

Know your out-of-pocket cost for care.

All Charges