Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

AMPICILLIN/SULBACT 3GM INJ

Facility

$33.00

Service Code	HCPCS J0295
Hospital Charge Code	3000034
Hospital Revenue Code	258
Min. Negotiated Rate	$23.10
Max. Negotiated Rate	$33.00
Rate for Payer: Aetna Commercial	$31.35
Rate for Payer: Aetna Medicare	$29.70
Rate for Payer: BCBS MT CHIP	$29.70
Rate for Payer: BCBS MT Closed Plan Network	$31.35
Rate for Payer: BCBS MT HealthLink	$29.70
Rate for Payer: BCBS MT Medicare	$29.70
Rate for Payer: BCBS MT POS	$31.35
Rate for Payer: BCBS MT Traditional	$33.00
Rate for Payer: Cash Price	$29.70
Rate for Payer: Cigna Commercial	$31.35
Rate for Payer: Cigna Medicare	$29.70
Rate for Payer: Medicaid All Medicaid	$30.36
Rate for Payer: Medicare All Medicare	$23.10
Rate for Payer: Monida Allegiance	$31.35
Rate for Payer: Monida First Choice Health	$32.01
Rate for Payer: Monida Montana Health Co-op	$31.35
Rate for Payer: Monida PacificSource	$31.35

AMPICILLIN/SULBACT 3GM INJ

Facility

$33.00

Service Code	HCPCS J0295
Hospital Charge Code	3000034
Hospital Revenue Code	258
Min. Negotiated Rate	$23.10
Max. Negotiated Rate	$33.00
Rate for Payer: Aetna Commercial	$31.35
Rate for Payer: Aetna Medicare	$29.70
Rate for Payer: BCBS MT CHIP	$29.70
Rate for Payer: BCBS MT Closed Plan Network	$31.35
Rate for Payer: BCBS MT HealthLink	$29.70
Rate for Payer: BCBS MT Medicare	$29.70
Rate for Payer: BCBS MT POS	$31.35
Rate for Payer: BCBS MT Traditional	$33.00
Rate for Payer: Cash Price	$29.70
Rate for Payer: Cigna Commercial	$31.35
Rate for Payer: Cigna Medicare	$29.70
Rate for Payer: Medicaid All Medicaid	$30.36
Rate for Payer: Medicare All Medicare	$23.10
Rate for Payer: Monida Allegiance	$31.35
Rate for Payer: Monida First Choice Health	$32.01
Rate for Payer: Monida Montana Health Co-op	$31.35
Rate for Payer: Monida PacificSource	$31.35

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

$64.00

Service Code	HCPCS 87075
Hospital Charge Code	4087075
Hospital Revenue Code	306
Min. Negotiated Rate	$44.80
Max. Negotiated Rate	$64.00
Rate for Payer: Aetna Commercial	$60.80
Rate for Payer: Aetna Medicare	$57.60
Rate for Payer: BCBS MT CHIP	$57.60
Rate for Payer: BCBS MT Closed Plan Network	$60.80
Rate for Payer: BCBS MT HealthLink	$57.60
Rate for Payer: BCBS MT Medicare	$57.60
Rate for Payer: BCBS MT POS	$60.80
Rate for Payer: BCBS MT Traditional	$64.00
Rate for Payer: Cash Price	$57.60
Rate for Payer: Cigna Commercial	$60.80
Rate for Payer: Cigna Medicare	$57.60
Rate for Payer: Medicaid All Medicaid	$58.88
Rate for Payer: Medicare All Medicare	$44.80
Rate for Payer: Monida Allegiance	$60.80
Rate for Payer: Monida First Choice Health	$62.08
Rate for Payer: Monida Montana Health Co-op	$60.80
Rate for Payer: Monida PacificSource	$60.80

.ANAEROBIC CULTURE

Facility

$64.00

Service Code	HCPCS 87075
Hospital Charge Code	4087075
Hospital Revenue Code	306
Min. Negotiated Rate	$44.80
Max. Negotiated Rate	$64.00
Rate for Payer: Aetna Commercial	$60.80
Rate for Payer: Aetna Medicare	$57.60
Rate for Payer: BCBS MT CHIP	$57.60
Rate for Payer: BCBS MT Closed Plan Network	$60.80
Rate for Payer: BCBS MT HealthLink	$57.60
Rate for Payer: BCBS MT Medicare	$57.60
Rate for Payer: BCBS MT POS	$60.80
Rate for Payer: BCBS MT Traditional	$64.00
Rate for Payer: Cash Price	$57.60
Rate for Payer: Cigna Commercial	$60.80
Rate for Payer: Cigna Medicare	$57.60
Rate for Payer: Medicaid All Medicaid	$58.88
Rate for Payer: Medicare All Medicare	$44.80
Rate for Payer: Monida Allegiance	$60.80
Rate for Payer: Monida First Choice Health	$62.08
Rate for Payer: Monida Montana Health Co-op	$60.80
Rate for Payer: Monida PacificSource	$60.80

ANA, IFA (164947)

Facility

$68.00

Service Code	HCPCS 86038
Hospital Charge Code	4086039
Hospital Revenue Code	300
Min. Negotiated Rate	$47.60
Max. Negotiated Rate	$68.00
Rate for Payer: Aetna Commercial	$64.60
Rate for Payer: Aetna Medicare	$61.20
Rate for Payer: BCBS MT CHIP	$61.20
Rate for Payer: BCBS MT Closed Plan Network	$64.60
Rate for Payer: BCBS MT HealthLink	$61.20
Rate for Payer: BCBS MT Medicare	$61.20
Rate for Payer: BCBS MT POS	$64.60
Rate for Payer: BCBS MT Traditional	$68.00
Rate for Payer: Cash Price	$61.20
Rate for Payer: Cigna Commercial	$64.60
Rate for Payer: Cigna Medicare	$61.20
Rate for Payer: Medicaid All Medicaid	$62.56
Rate for Payer: Medicare All Medicare	$47.60
Rate for Payer: Monida Allegiance	$64.60
Rate for Payer: Monida First Choice Health	$65.96
Rate for Payer: Monida Montana Health Co-op	$64.60
Rate for Payer: Monida PacificSource	$64.60

ANA, IFA (164947)

Facility

$68.00

Service Code	HCPCS 86038
Hospital Charge Code	4086039
Hospital Revenue Code	300
Min. Negotiated Rate	$47.60
Max. Negotiated Rate	$68.00
Rate for Payer: Aetna Commercial	$64.60
Rate for Payer: Aetna Medicare	$61.20
Rate for Payer: BCBS MT CHIP	$61.20
Rate for Payer: BCBS MT Closed Plan Network	$64.60
Rate for Payer: BCBS MT HealthLink	$61.20
Rate for Payer: BCBS MT Medicare	$61.20
Rate for Payer: BCBS MT POS	$64.60
Rate for Payer: BCBS MT Traditional	$68.00
Rate for Payer: Cash Price	$61.20
Rate for Payer: Cigna Commercial	$64.60
Rate for Payer: Cigna Medicare	$61.20
Rate for Payer: Medicaid All Medicaid	$62.56
Rate for Payer: Medicare All Medicare	$47.60
Rate for Payer: Monida Allegiance	$64.60
Rate for Payer: Monida First Choice Health	$65.96
Rate for Payer: Monida Montana Health Co-op	$64.60
Rate for Payer: Monida PacificSource	$64.60

ANA SCREEN WITH REFLEX (164863)

Facility

$68.00

Service Code	HCPCS 86038
Hospital Charge Code	4086038
Hospital Revenue Code	300
Min. Negotiated Rate	$47.60
Max. Negotiated Rate	$68.00
Rate for Payer: Aetna Commercial	$64.60
Rate for Payer: Aetna Medicare	$61.20
Rate for Payer: BCBS MT CHIP	$61.20
Rate for Payer: BCBS MT Closed Plan Network	$64.60
Rate for Payer: BCBS MT HealthLink	$61.20
Rate for Payer: BCBS MT Medicare	$61.20
Rate for Payer: BCBS MT POS	$64.60
Rate for Payer: BCBS MT Traditional	$68.00
Rate for Payer: Cash Price	$61.20
Rate for Payer: Cigna Commercial	$64.60
Rate for Payer: Cigna Medicare	$61.20
Rate for Payer: Medicaid All Medicaid	$62.56
Rate for Payer: Medicare All Medicare	$47.60
Rate for Payer: Monida Allegiance	$64.60
Rate for Payer: Monida First Choice Health	$65.96
Rate for Payer: Monida Montana Health Co-op	$64.60
Rate for Payer: Monida PacificSource	$64.60

ANA SCREEN WITH REFLEX (164863)

Facility

$68.00

Service Code	HCPCS 86038
Hospital Charge Code	4086038
Hospital Revenue Code	300
Min. Negotiated Rate	$47.60
Max. Negotiated Rate	$68.00
Rate for Payer: Aetna Commercial	$64.60
Rate for Payer: Aetna Medicare	$61.20
Rate for Payer: BCBS MT CHIP	$61.20
Rate for Payer: BCBS MT Closed Plan Network	$64.60
Rate for Payer: BCBS MT HealthLink	$61.20
Rate for Payer: BCBS MT Medicare	$61.20
Rate for Payer: BCBS MT POS	$64.60
Rate for Payer: BCBS MT Traditional	$68.00
Rate for Payer: Cash Price	$61.20
Rate for Payer: Cigna Commercial	$64.60
Rate for Payer: Cigna Medicare	$61.20
Rate for Payer: Medicaid All Medicaid	$62.56
Rate for Payer: Medicare All Medicare	$47.60
Rate for Payer: Monida Allegiance	$64.60
Rate for Payer: Monida First Choice Health	$65.96
Rate for Payer: Monida Montana Health Co-op	$64.60
Rate for Payer: Monida PacificSource	$64.60

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 COLON& EGD 00813

Facility

$833.00

Service Code	HCPCS 00813
Hospital Charge Code	5840008
Hospital Revenue Code	370
Min. Negotiated Rate	$583.10
Max. Negotiated Rate	$833.00
Rate for Payer: Aetna Commercial	$791.35
Rate for Payer: Aetna Medicare	$749.70
Rate for Payer: BCBS MT CHIP	$749.70
Rate for Payer: BCBS MT Closed Plan Network	$791.35
Rate for Payer: BCBS MT HealthLink	$749.70
Rate for Payer: BCBS MT Medicare	$749.70
Rate for Payer: BCBS MT POS	$791.35
Rate for Payer: BCBS MT Traditional	$833.00
Rate for Payer: Cash Price	$749.70
Rate for Payer: Cigna Commercial	$791.35
Rate for Payer: Cigna Medicare	$749.70
Rate for Payer: Medicaid All Medicaid	$766.36
Rate for Payer: Medicare All Medicare	$583.10
Rate for Payer: Monida Allegiance	$791.35
Rate for Payer: Monida First Choice Health	$808.01
Rate for Payer: Monida Montana Health Co-op	$791.35
Rate for Payer: Monida PacificSource	$791.35

ANESTHESIA COLON& EGD 00813

Facility

$833.00

Service Code	HCPCS 00813
Hospital Charge Code	5840008
Hospital Revenue Code	370
Min. Negotiated Rate	$583.10
Max. Negotiated Rate	$833.00
Rate for Payer: Aetna Commercial	$791.35
Rate for Payer: Aetna Medicare	$749.70
Rate for Payer: BCBS MT CHIP	$749.70
Rate for Payer: BCBS MT Closed Plan Network	$791.35
Rate for Payer: BCBS MT HealthLink	$749.70
Rate for Payer: BCBS MT Medicare	$749.70
Rate for Payer: BCBS MT POS	$791.35
Rate for Payer: BCBS MT Traditional	$833.00
Rate for Payer: Cash Price	$749.70
Rate for Payer: Cigna Commercial	$791.35
Rate for Payer: Cigna Medicare	$749.70
Rate for Payer: Medicaid All Medicaid	$766.36
Rate for Payer: Medicare All Medicare	$583.10
Rate for Payer: Monida Allegiance	$791.35
Rate for Payer: Monida First Choice Health	$808.01
Rate for Payer: Monida Montana Health Co-op	$791.35
Rate for Payer: Monida PacificSource	$791.35

ANESTHESIA COLONOSCOPY 00811

Facility

$867.00

Service Code	HCPCS 00811
Hospital Charge Code	5800811
Hospital Revenue Code	370
Min. Negotiated Rate	$606.90
Max. Negotiated Rate	$867.00
Rate for Payer: Aetna Commercial	$823.65
Rate for Payer: Aetna Medicare	$780.30
Rate for Payer: BCBS MT CHIP	$780.30
Rate for Payer: BCBS MT Closed Plan Network	$823.65
Rate for Payer: BCBS MT HealthLink	$780.30
Rate for Payer: BCBS MT Medicare	$780.30
Rate for Payer: BCBS MT POS	$823.65
Rate for Payer: BCBS MT Traditional	$867.00
Rate for Payer: Cash Price	$780.30
Rate for Payer: Cigna Commercial	$823.65
Rate for Payer: Cigna Medicare	$780.30
Rate for Payer: Medicaid All Medicaid	$797.64
Rate for Payer: Medicare All Medicare	$606.90
Rate for Payer: Monida Allegiance	$823.65
Rate for Payer: Monida First Choice Health	$840.99
Rate for Payer: Monida Montana Health Co-op	$823.65
Rate for Payer: Monida PacificSource	$823.65

ANESTHESIA COLONOSCOPY 00811

Facility

$867.00

Service Code	HCPCS 00811
Hospital Charge Code	5800811
Hospital Revenue Code	370
Min. Negotiated Rate	$606.90
Max. Negotiated Rate	$867.00
Rate for Payer: Aetna Commercial	$823.65
Rate for Payer: Aetna Medicare	$780.30
Rate for Payer: BCBS MT CHIP	$780.30
Rate for Payer: BCBS MT Closed Plan Network	$823.65
Rate for Payer: BCBS MT HealthLink	$780.30
Rate for Payer: BCBS MT Medicare	$780.30
Rate for Payer: BCBS MT POS	$823.65
Rate for Payer: BCBS MT Traditional	$867.00
Rate for Payer: Cash Price	$780.30
Rate for Payer: Cigna Commercial	$823.65
Rate for Payer: Cigna Medicare	$780.30
Rate for Payer: Medicaid All Medicaid	$797.64
Rate for Payer: Medicare All Medicare	$606.90
Rate for Payer: Monida Allegiance	$823.65
Rate for Payer: Monida First Choice Health	$840.99
Rate for Payer: Monida Montana Health Co-op	$823.65
Rate for Payer: Monida PacificSource	$823.65

ANESTHESIA COLONOSCOPY 00812

Facility

$827.00

Service Code	HCPCS 00812
Hospital Charge Code	5840005
Hospital Revenue Code	370
Min. Negotiated Rate	$578.90
Max. Negotiated Rate	$827.00
Rate for Payer: Aetna Commercial	$785.65
Rate for Payer: Aetna Medicare	$744.30
Rate for Payer: BCBS MT CHIP	$744.30
Rate for Payer: BCBS MT Closed Plan Network	$785.65
Rate for Payer: BCBS MT HealthLink	$744.30
Rate for Payer: BCBS MT Medicare	$744.30
Rate for Payer: BCBS MT POS	$785.65
Rate for Payer: BCBS MT Traditional	$827.00
Rate for Payer: Cash Price	$744.30
Rate for Payer: Cigna Commercial	$785.65
Rate for Payer: Cigna Medicare	$744.30
Rate for Payer: Medicaid All Medicaid	$760.84
Rate for Payer: Medicare All Medicare	$578.90
Rate for Payer: Monida Allegiance	$785.65
Rate for Payer: Monida First Choice Health	$802.19
Rate for Payer: Monida Montana Health Co-op	$785.65
Rate for Payer: Monida PacificSource	$785.65

ANESTHESIA COLONOSCOPY 00812

Facility

$827.00

Service Code	HCPCS 00812
Hospital Charge Code	5840005
Hospital Revenue Code	370
Min. Negotiated Rate	$578.90
Max. Negotiated Rate	$827.00
Rate for Payer: Aetna Commercial	$785.65
Rate for Payer: Aetna Medicare	$744.30
Rate for Payer: BCBS MT CHIP	$744.30
Rate for Payer: BCBS MT Closed Plan Network	$785.65
Rate for Payer: BCBS MT HealthLink	$744.30
Rate for Payer: BCBS MT Medicare	$744.30
Rate for Payer: BCBS MT POS	$785.65
Rate for Payer: BCBS MT Traditional	$827.00
Rate for Payer: Cash Price	$744.30
Rate for Payer: Cigna Commercial	$785.65
Rate for Payer: Cigna Medicare	$744.30
Rate for Payer: Medicaid All Medicaid	$760.84
Rate for Payer: Medicare All Medicare	$578.90
Rate for Payer: Monida Allegiance	$785.65
Rate for Payer: Monida First Choice Health	$802.19
Rate for Payer: Monida Montana Health Co-op	$785.65
Rate for Payer: Monida PacificSource	$785.65

ANESTHESIA ENDO 00731

Facility

$866.00

Service Code	HCPCS 00731
Hospital Charge Code	5800812
Hospital Revenue Code	370
Min. Negotiated Rate	$606.20
Max. Negotiated Rate	$866.00
Rate for Payer: Aetna Commercial	$822.70
Rate for Payer: Aetna Medicare	$779.40
Rate for Payer: BCBS MT CHIP	$779.40
Rate for Payer: BCBS MT Closed Plan Network	$822.70
Rate for Payer: BCBS MT HealthLink	$779.40
Rate for Payer: BCBS MT Medicare	$779.40
Rate for Payer: BCBS MT POS	$822.70
Rate for Payer: BCBS MT Traditional	$866.00
Rate for Payer: Cash Price	$779.40
Rate for Payer: Cigna Commercial	$822.70
Rate for Payer: Cigna Medicare	$779.40
Rate for Payer: Medicaid All Medicaid	$796.72
Rate for Payer: Medicare All Medicare	$606.20
Rate for Payer: Monida Allegiance	$822.70
Rate for Payer: Monida First Choice Health	$840.02
Rate for Payer: Monida Montana Health Co-op	$822.70
Rate for Payer: Monida PacificSource	$822.70

ANESTHESIA ENDO 00731

Facility

$866.00

Service Code	HCPCS 00731
Hospital Charge Code	5800812
Hospital Revenue Code	370
Min. Negotiated Rate	$606.20
Max. Negotiated Rate	$866.00
Rate for Payer: Aetna Commercial	$822.70
Rate for Payer: Aetna Medicare	$779.40
Rate for Payer: BCBS MT CHIP	$779.40
Rate for Payer: BCBS MT Closed Plan Network	$822.70
Rate for Payer: BCBS MT HealthLink	$779.40
Rate for Payer: BCBS MT Medicare	$779.40
Rate for Payer: BCBS MT POS	$822.70
Rate for Payer: BCBS MT Traditional	$866.00
Rate for Payer: Cash Price	$779.40
Rate for Payer: Cigna Commercial	$822.70
Rate for Payer: Cigna Medicare	$779.40
Rate for Payer: Medicaid All Medicaid	$796.72
Rate for Payer: Medicare All Medicare	$606.20
Rate for Payer: Monida Allegiance	$822.70
Rate for Payer: Monida First Choice Health	$840.02
Rate for Payer: Monida Montana Health Co-op	$822.70
Rate for Payer: Monida PacificSource	$822.70

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

$336.00

Service Code	HCPCS L1906
Hospital Charge Code	8001906
Hospital Revenue Code	290
Min. Negotiated Rate	$235.20
Max. Negotiated Rate	$336.00
Rate for Payer: Aetna Commercial	$319.20
Rate for Payer: Aetna Medicare	$302.40
Rate for Payer: BCBS MT CHIP	$302.40
Rate for Payer: BCBS MT Closed Plan Network	$319.20
Rate for Payer: BCBS MT HealthLink	$302.40
Rate for Payer: BCBS MT Medicare	$302.40
Rate for Payer: BCBS MT POS	$319.20
Rate for Payer: BCBS MT Traditional	$336.00
Rate for Payer: Cash Price	$302.40
Rate for Payer: Cigna Commercial	$319.20
Rate for Payer: Cigna Medicare	$302.40
Rate for Payer: Medicaid All Medicaid	$309.12
Rate for Payer: Medicare All Medicare	$235.20
Rate for Payer: Monida Allegiance	$319.20
Rate for Payer: Monida First Choice Health	$325.92
Rate for Payer: Monida Montana Health Co-op	$319.20
Rate for Payer: Monida PacificSource	$319.20

ANKLE BRACE

Facility

$336.00

Service Code	HCPCS L1906
Hospital Charge Code	8001906
Hospital Revenue Code	290
Min. Negotiated Rate	$235.20
Max. Negotiated Rate	$336.00
Rate for Payer: Aetna Commercial	$319.20
Rate for Payer: Aetna Medicare	$302.40
Rate for Payer: BCBS MT CHIP	$302.40
Rate for Payer: BCBS MT Closed Plan Network	$319.20
Rate for Payer: BCBS MT HealthLink	$302.40
Rate for Payer: BCBS MT Medicare	$302.40
Rate for Payer: BCBS MT POS	$319.20
Rate for Payer: BCBS MT Traditional	$336.00
Rate for Payer: Cash Price	$302.40
Rate for Payer: Cigna Commercial	$319.20
Rate for Payer: Cigna Medicare	$302.40
Rate for Payer: Medicaid All Medicaid	$309.12
Rate for Payer: Medicare All Medicare	$235.20
Rate for Payer: Monida Allegiance	$319.20
Rate for Payer: Monida First Choice Health	$325.92
Rate for Payer: Monida Montana Health Co-op	$319.20
Rate for Payer: Monida PacificSource	$319.20

ANKLE BRACE AIR GEL 9.0''

Facility

$49.00

Hospital Charge Code	2893172
Hospital Revenue Code	290
Min. Negotiated Rate	$34.30
Max. Negotiated Rate	$49.00
Rate for Payer: Aetna Commercial	$46.55
Rate for Payer: Aetna Medicare	$44.10
Rate for Payer: BCBS MT CHIP	$44.10
Rate for Payer: BCBS MT Closed Plan Network	$46.55
Rate for Payer: BCBS MT HealthLink	$44.10
Rate for Payer: BCBS MT Medicare	$44.10
Rate for Payer: BCBS MT POS	$46.55
Rate for Payer: BCBS MT Traditional	$49.00
Rate for Payer: Cash Price	$44.10
Rate for Payer: Cigna Commercial	$46.55
Rate for Payer: Cigna Medicare	$44.10
Rate for Payer: Medicaid All Medicaid	$45.08
Rate for Payer: Medicare All Medicare	$34.30
Rate for Payer: Monida Allegiance	$46.55
Rate for Payer: Monida First Choice Health	$47.53
Rate for Payer: Monida Montana Health Co-op	$46.55
Rate for Payer: Monida PacificSource	$46.55

Know your out-of-pocket cost for care.

All Charges