Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

FREESTYLE LIBRE 3 SENSOR SPEC ORDER

Facility

$262.00

Service Code	HCPCS A4238
Hospital Charge Code	3000558
Hospital Revenue Code	259
Min. Negotiated Rate	$183.40
Max. Negotiated Rate	$262.00
Rate for Payer: Aetna Commercial	$248.90
Rate for Payer: Aetna Medicare	$235.80
Rate for Payer: BCBS MT CHIP	$235.80
Rate for Payer: BCBS MT Closed Plan Network	$248.90
Rate for Payer: BCBS MT HealthLink	$235.80
Rate for Payer: BCBS MT Medicare	$235.80
Rate for Payer: BCBS MT POS	$248.90
Rate for Payer: BCBS MT Traditional	$262.00
Rate for Payer: Cash Price	$235.80
Rate for Payer: Cigna Commercial	$248.90
Rate for Payer: Cigna Medicare	$235.80
Rate for Payer: Medicaid All Medicaid	$241.04
Rate for Payer: Medicare All Medicare	$183.40
Rate for Payer: Monida Allegiance	$248.90
Rate for Payer: Monida First Choice Health	$254.14
Rate for Payer: Monida Montana Health Co-op	$248.90
Rate for Payer: Monida PacificSource	$248.90

FSH (004309)

Facility

$77.00

Service Code	CPT 83001
Hospital Charge Code	4083001
Hospital Revenue Code	300
Min. Negotiated Rate	$53.90
Max. Negotiated Rate	$77.00
Rate for Payer: Aetna Commercial	$73.15
Rate for Payer: Aetna Medicare	$69.30
Rate for Payer: BCBS MT CHIP	$69.30
Rate for Payer: BCBS MT Closed Plan Network	$73.15
Rate for Payer: BCBS MT HealthLink	$69.30
Rate for Payer: BCBS MT Medicare	$69.30
Rate for Payer: BCBS MT POS	$73.15
Rate for Payer: BCBS MT Traditional	$77.00
Rate for Payer: Cash Price	$69.30
Rate for Payer: Cigna Commercial	$73.15
Rate for Payer: Cigna Medicare	$69.30
Rate for Payer: Medicaid All Medicaid	$70.84
Rate for Payer: Medicare All Medicare	$53.90
Rate for Payer: Monida Allegiance	$73.15
Rate for Payer: Monida First Choice Health	$74.69
Rate for Payer: Monida Montana Health Co-op	$73.15
Rate for Payer: Monida PacificSource	$73.15

FSH (004309)

Facility

$77.00

Service Code	CPT 83001
Hospital Charge Code	4083001
Hospital Revenue Code	300
Min. Negotiated Rate	$53.90
Max. Negotiated Rate	$77.00
Rate for Payer: Aetna Commercial	$73.15
Rate for Payer: Aetna Medicare	$69.30
Rate for Payer: BCBS MT CHIP	$69.30
Rate for Payer: BCBS MT Closed Plan Network	$73.15
Rate for Payer: BCBS MT HealthLink	$69.30
Rate for Payer: BCBS MT Medicare	$69.30
Rate for Payer: BCBS MT POS	$73.15
Rate for Payer: BCBS MT Traditional	$77.00
Rate for Payer: Cash Price	$69.30
Rate for Payer: Cigna Commercial	$73.15
Rate for Payer: Cigna Medicare	$69.30
Rate for Payer: Medicaid All Medicaid	$70.84
Rate for Payer: Medicare All Medicare	$53.90
Rate for Payer: Monida Allegiance	$73.15
Rate for Payer: Monida First Choice Health	$74.69
Rate for Payer: Monida Montana Health Co-op	$73.15
Rate for Payer: Monida PacificSource	$73.15

FSH AND LH

Facility

$130.00

Service Code	CPT 83001
Hospital Charge Code	4087987
Hospital Revenue Code	302
Min. Negotiated Rate	$91.00
Max. Negotiated Rate	$130.00
Rate for Payer: Aetna Commercial	$123.50
Rate for Payer: Aetna Medicare	$117.00
Rate for Payer: BCBS MT CHIP	$117.00
Rate for Payer: BCBS MT Closed Plan Network	$123.50
Rate for Payer: BCBS MT HealthLink	$117.00
Rate for Payer: BCBS MT Medicare	$117.00
Rate for Payer: BCBS MT POS	$123.50
Rate for Payer: BCBS MT Traditional	$130.00
Rate for Payer: Cash Price	$117.00
Rate for Payer: Cigna Commercial	$123.50
Rate for Payer: Cigna Medicare	$117.00
Rate for Payer: Medicaid All Medicaid	$119.60
Rate for Payer: Medicare All Medicare	$91.00
Rate for Payer: Monida Allegiance	$123.50
Rate for Payer: Monida First Choice Health	$126.10
Rate for Payer: Monida Montana Health Co-op	$123.50
Rate for Payer: Monida PacificSource	$123.50

FSH AND LH

Facility

$130.00

Service Code	CPT 83001
Hospital Charge Code	4087987
Hospital Revenue Code	302
Min. Negotiated Rate	$91.00
Max. Negotiated Rate	$130.00
Rate for Payer: Aetna Commercial	$123.50
Rate for Payer: Aetna Medicare	$117.00
Rate for Payer: BCBS MT CHIP	$117.00
Rate for Payer: BCBS MT Closed Plan Network	$123.50
Rate for Payer: BCBS MT HealthLink	$117.00
Rate for Payer: BCBS MT Medicare	$117.00
Rate for Payer: BCBS MT POS	$123.50
Rate for Payer: BCBS MT Traditional	$130.00
Rate for Payer: Cash Price	$117.00
Rate for Payer: Cigna Commercial	$123.50
Rate for Payer: Cigna Medicare	$117.00
Rate for Payer: Medicaid All Medicaid	$119.60
Rate for Payer: Medicare All Medicare	$91.00
Rate for Payer: Monida Allegiance	$123.50
Rate for Payer: Monida First Choice Health	$126.10
Rate for Payer: Monida Montana Health Co-op	$123.50
Rate for Payer: Monida PacificSource	$123.50

FUNGAL CULTURE

Facility

$110.00

Service Code	CPT 87102
Hospital Charge Code	4088042
Hospital Revenue Code	302
Min. Negotiated Rate	$77.00
Max. Negotiated Rate	$110.00
Rate for Payer: Aetna Commercial	$104.50
Rate for Payer: Aetna Medicare	$99.00
Rate for Payer: BCBS MT CHIP	$99.00
Rate for Payer: BCBS MT Closed Plan Network	$104.50
Rate for Payer: BCBS MT HealthLink	$99.00
Rate for Payer: BCBS MT Medicare	$99.00
Rate for Payer: BCBS MT POS	$104.50
Rate for Payer: BCBS MT Traditional	$110.00
Rate for Payer: Cash Price	$99.00
Rate for Payer: Cigna Commercial	$104.50
Rate for Payer: Cigna Medicare	$99.00
Rate for Payer: Medicaid All Medicaid	$101.20
Rate for Payer: Medicare All Medicare	$77.00
Rate for Payer: Monida Allegiance	$104.50
Rate for Payer: Monida First Choice Health	$106.70
Rate for Payer: Monida Montana Health Co-op	$104.50
Rate for Payer: Monida PacificSource	$104.50

FUNGAL CULTURE

Facility

$110.00

Service Code	CPT 87102
Hospital Charge Code	4088042
Hospital Revenue Code	302
Min. Negotiated Rate	$77.00
Max. Negotiated Rate	$110.00
Rate for Payer: Aetna Commercial	$104.50
Rate for Payer: Aetna Medicare	$99.00
Rate for Payer: BCBS MT CHIP	$99.00
Rate for Payer: BCBS MT Closed Plan Network	$104.50
Rate for Payer: BCBS MT HealthLink	$99.00
Rate for Payer: BCBS MT Medicare	$99.00
Rate for Payer: BCBS MT POS	$104.50
Rate for Payer: BCBS MT Traditional	$110.00
Rate for Payer: Cash Price	$99.00
Rate for Payer: Cigna Commercial	$104.50
Rate for Payer: Cigna Medicare	$99.00
Rate for Payer: Medicaid All Medicaid	$101.20
Rate for Payer: Medicare All Medicare	$77.00
Rate for Payer: Monida Allegiance	$104.50
Rate for Payer: Monida First Choice Health	$106.70
Rate for Payer: Monida Montana Health Co-op	$104.50
Rate for Payer: Monida PacificSource	$104.50

FUROSEMIDE INJ [40 MG/4 ML]

Facility

$14.00

Service Code	HCPCS J1938
Hospital Charge Code	3000192
Hospital Revenue Code	259
Min. Negotiated Rate	$9.80
Max. Negotiated Rate	$14.00
Rate for Payer: Aetna Commercial	$13.30
Rate for Payer: Aetna Medicare	$12.60
Rate for Payer: BCBS MT CHIP	$12.60
Rate for Payer: BCBS MT Closed Plan Network	$13.30
Rate for Payer: BCBS MT HealthLink	$12.60
Rate for Payer: BCBS MT Medicare	$12.60
Rate for Payer: BCBS MT POS	$13.30
Rate for Payer: BCBS MT Traditional	$14.00
Rate for Payer: Cash Price	$12.60
Rate for Payer: Cigna Commercial	$13.30
Rate for Payer: Cigna Medicare	$12.60
Rate for Payer: Medicaid All Medicaid	$12.88
Rate for Payer: Medicare All Medicare	$9.80
Rate for Payer: Monida Allegiance	$13.30
Rate for Payer: Monida First Choice Health	$13.58
Rate for Payer: Monida Montana Health Co-op	$13.30
Rate for Payer: Monida PacificSource	$13.30

FUROSEMIDE INJ [40 MG/4 ML]

Facility

$14.00

Service Code	HCPCS J1938
Hospital Charge Code	3000192
Hospital Revenue Code	259
Min. Negotiated Rate	$9.80
Max. Negotiated Rate	$14.00
Rate for Payer: Aetna Commercial	$13.30
Rate for Payer: Aetna Medicare	$12.60
Rate for Payer: BCBS MT CHIP	$12.60
Rate for Payer: BCBS MT Closed Plan Network	$13.30
Rate for Payer: BCBS MT HealthLink	$12.60
Rate for Payer: BCBS MT Medicare	$12.60
Rate for Payer: BCBS MT POS	$13.30
Rate for Payer: BCBS MT Traditional	$14.00
Rate for Payer: Cash Price	$12.60
Rate for Payer: Cigna Commercial	$13.30
Rate for Payer: Cigna Medicare	$12.60
Rate for Payer: Medicaid All Medicaid	$12.88
Rate for Payer: Medicare All Medicare	$9.80
Rate for Payer: Monida Allegiance	$13.30
Rate for Payer: Monida First Choice Health	$13.58
Rate for Payer: Monida Montana Health Co-op	$13.30
Rate for Payer: Monida PacificSource	$13.30

FUROSEMIDE TAB [20 MG]

Facility

$8.00

Service Code	HCPCS J8499
Hospital Charge Code	3000193
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

FUROSEMIDE TAB [20 MG]

Facility

$8.00

Service Code	HCPCS J8499
Hospital Charge Code	3000193
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

FUROSEMIDE TAB [40 MG]

Facility

$8.00

Service Code	HCPCS J8499
Hospital Charge Code	3000194
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

FUROSEMIDE TAB [40 MG]

Facility

$8.00

Service Code	HCPCS J8499
Hospital Charge Code	3000194
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

FX CLOSED ANKLE DISTAL W/O MAN

Facility

$659.00

Service Code	CPT 27840
Hospital Charge Code	8027840
Hospital Revenue Code	521
Min. Negotiated Rate	$461.30
Max. Negotiated Rate	$659.00
Rate for Payer: Aetna Commercial	$626.05
Rate for Payer: Aetna Medicare	$593.10
Rate for Payer: BCBS MT CHIP	$593.10
Rate for Payer: BCBS MT Closed Plan Network	$626.05
Rate for Payer: BCBS MT HealthLink	$593.10
Rate for Payer: BCBS MT Medicare	$593.10
Rate for Payer: BCBS MT POS	$626.05
Rate for Payer: BCBS MT Traditional	$659.00
Rate for Payer: Cash Price	$593.10
Rate for Payer: Cigna Commercial	$626.05
Rate for Payer: Cigna Medicare	$593.10
Rate for Payer: Medicaid All Medicaid	$606.28
Rate for Payer: Medicare All Medicare	$461.30
Rate for Payer: Monida Allegiance	$626.05
Rate for Payer: Monida First Choice Health	$639.23
Rate for Payer: Monida Montana Health Co-op	$626.05
Rate for Payer: Monida PacificSource	$626.05

FX CLOSED ANKLE DISTAL W/O MAN

Facility

$659.00

Service Code	CPT 27840
Hospital Charge Code	8027840
Hospital Revenue Code	521
Min. Negotiated Rate	$461.30
Max. Negotiated Rate	$659.00
Rate for Payer: Aetna Commercial	$626.05
Rate for Payer: Aetna Medicare	$593.10
Rate for Payer: BCBS MT CHIP	$593.10
Rate for Payer: BCBS MT Closed Plan Network	$626.05
Rate for Payer: BCBS MT HealthLink	$593.10
Rate for Payer: BCBS MT Medicare	$593.10
Rate for Payer: BCBS MT POS	$626.05
Rate for Payer: BCBS MT Traditional	$659.00
Rate for Payer: Cash Price	$593.10
Rate for Payer: Cigna Commercial	$626.05
Rate for Payer: Cigna Medicare	$593.10
Rate for Payer: Medicaid All Medicaid	$606.28
Rate for Payer: Medicare All Medicare	$461.30
Rate for Payer: Monida Allegiance	$626.05
Rate for Payer: Monida First Choice Health	$639.23
Rate for Payer: Monida Montana Health Co-op	$626.05
Rate for Payer: Monida PacificSource	$626.05

FX CLOSED ARM (SCAPHOID) W/O MANIPUL

Facility

$649.00

Service Code	CPT 25622
Hospital Charge Code	8025622
Hospital Revenue Code	521
Min. Negotiated Rate	$454.30
Max. Negotiated Rate	$649.00
Rate for Payer: Aetna Commercial	$616.55
Rate for Payer: Aetna Medicare	$584.10
Rate for Payer: BCBS MT CHIP	$584.10
Rate for Payer: BCBS MT Closed Plan Network	$616.55
Rate for Payer: BCBS MT HealthLink	$584.10
Rate for Payer: BCBS MT Medicare	$584.10
Rate for Payer: BCBS MT POS	$616.55
Rate for Payer: BCBS MT Traditional	$649.00
Rate for Payer: Cash Price	$584.10
Rate for Payer: Cigna Commercial	$616.55
Rate for Payer: Cigna Medicare	$584.10
Rate for Payer: Medicaid All Medicaid	$597.08
Rate for Payer: Medicare All Medicare	$454.30
Rate for Payer: Monida Allegiance	$616.55
Rate for Payer: Monida First Choice Health	$629.53
Rate for Payer: Monida Montana Health Co-op	$616.55
Rate for Payer: Monida PacificSource	$616.55

FX CLOSED ARM (SCAPHOID) W/O MANIPUL

Facility

$649.00

Service Code	CPT 25622
Hospital Charge Code	8025622
Hospital Revenue Code	521
Min. Negotiated Rate	$454.30
Max. Negotiated Rate	$649.00
Rate for Payer: Aetna Commercial	$616.55
Rate for Payer: Aetna Medicare	$584.10
Rate for Payer: BCBS MT CHIP	$584.10
Rate for Payer: BCBS MT Closed Plan Network	$616.55
Rate for Payer: BCBS MT HealthLink	$584.10
Rate for Payer: BCBS MT Medicare	$584.10
Rate for Payer: BCBS MT POS	$616.55
Rate for Payer: BCBS MT Traditional	$649.00
Rate for Payer: Cash Price	$584.10
Rate for Payer: Cigna Commercial	$616.55
Rate for Payer: Cigna Medicare	$584.10
Rate for Payer: Medicaid All Medicaid	$597.08
Rate for Payer: Medicare All Medicare	$454.30
Rate for Payer: Monida Allegiance	$616.55
Rate for Payer: Monida First Choice Health	$629.53
Rate for Payer: Monida Montana Health Co-op	$616.55
Rate for Payer: Monida PacificSource	$616.55

FX CLOSED CARPAL BONE EA BONE W/O MANIP

Facility

$682.00

Service Code	CPT 25630
Hospital Charge Code	8025630
Hospital Revenue Code	521
Min. Negotiated Rate	$477.40
Max. Negotiated Rate	$682.00
Rate for Payer: Aetna Commercial	$647.90
Rate for Payer: Aetna Medicare	$613.80
Rate for Payer: BCBS MT CHIP	$613.80
Rate for Payer: BCBS MT Closed Plan Network	$647.90
Rate for Payer: BCBS MT HealthLink	$613.80
Rate for Payer: BCBS MT Medicare	$613.80
Rate for Payer: BCBS MT POS	$647.90
Rate for Payer: BCBS MT Traditional	$682.00
Rate for Payer: Cash Price	$613.80
Rate for Payer: Cigna Commercial	$647.90
Rate for Payer: Cigna Medicare	$613.80
Rate for Payer: Medicaid All Medicaid	$627.44
Rate for Payer: Medicare All Medicare	$477.40
Rate for Payer: Monida Allegiance	$647.90
Rate for Payer: Monida First Choice Health	$661.54
Rate for Payer: Monida Montana Health Co-op	$647.90
Rate for Payer: Monida PacificSource	$647.90

FX CLOSED CARPAL BONE EA BONE W/O MANIP

Facility

$682.00

Service Code	CPT 25630
Hospital Charge Code	8025630
Hospital Revenue Code	521
Min. Negotiated Rate	$477.40
Max. Negotiated Rate	$682.00
Rate for Payer: Aetna Commercial	$647.90
Rate for Payer: Aetna Medicare	$613.80
Rate for Payer: BCBS MT CHIP	$613.80
Rate for Payer: BCBS MT Closed Plan Network	$647.90
Rate for Payer: BCBS MT HealthLink	$613.80
Rate for Payer: BCBS MT Medicare	$613.80
Rate for Payer: BCBS MT POS	$647.90
Rate for Payer: BCBS MT Traditional	$682.00
Rate for Payer: Cash Price	$613.80
Rate for Payer: Cigna Commercial	$647.90
Rate for Payer: Cigna Medicare	$613.80
Rate for Payer: Medicaid All Medicaid	$627.44
Rate for Payer: Medicare All Medicare	$477.40
Rate for Payer: Monida Allegiance	$647.90
Rate for Payer: Monida First Choice Health	$661.54
Rate for Payer: Monida Montana Health Co-op	$647.90
Rate for Payer: Monida PacificSource	$647.90

FX CLOSED DISTAL FIBULA W/O MAN

Facility

$726.00

Service Code	CPT 27786
Hospital Charge Code	8027786
Hospital Revenue Code	521
Min. Negotiated Rate	$508.20
Max. Negotiated Rate	$726.00
Rate for Payer: Aetna Commercial	$689.70
Rate for Payer: Aetna Medicare	$653.40
Rate for Payer: BCBS MT CHIP	$653.40
Rate for Payer: BCBS MT Closed Plan Network	$689.70
Rate for Payer: BCBS MT HealthLink	$653.40
Rate for Payer: BCBS MT Medicare	$653.40
Rate for Payer: BCBS MT POS	$689.70
Rate for Payer: BCBS MT Traditional	$726.00
Rate for Payer: Cash Price	$653.40
Rate for Payer: Cigna Commercial	$689.70
Rate for Payer: Cigna Medicare	$653.40
Rate for Payer: Medicaid All Medicaid	$667.92
Rate for Payer: Medicare All Medicare	$508.20
Rate for Payer: Monida Allegiance	$689.70
Rate for Payer: Monida First Choice Health	$704.22
Rate for Payer: Monida Montana Health Co-op	$689.70
Rate for Payer: Monida PacificSource	$689.70

FX CLOSED DISTAL FIBULA W/O MAN

Facility

$726.00

Service Code	CPT 27786
Hospital Charge Code	8027786
Hospital Revenue Code	521
Min. Negotiated Rate	$508.20
Max. Negotiated Rate	$726.00
Rate for Payer: Aetna Commercial	$689.70
Rate for Payer: Aetna Medicare	$653.40
Rate for Payer: BCBS MT CHIP	$653.40
Rate for Payer: BCBS MT Closed Plan Network	$689.70
Rate for Payer: BCBS MT HealthLink	$653.40
Rate for Payer: BCBS MT Medicare	$653.40
Rate for Payer: BCBS MT POS	$689.70
Rate for Payer: BCBS MT Traditional	$726.00
Rate for Payer: Cash Price	$653.40
Rate for Payer: Cigna Commercial	$689.70
Rate for Payer: Cigna Medicare	$653.40
Rate for Payer: Medicaid All Medicaid	$667.92
Rate for Payer: Medicare All Medicare	$508.20
Rate for Payer: Monida Allegiance	$689.70
Rate for Payer: Monida First Choice Health	$704.22
Rate for Payer: Monida Montana Health Co-op	$689.70
Rate for Payer: Monida PacificSource	$689.70

FX CLOSED DISTAL PHLANG W/O MANIPULATION

Facility

$594.00

Service Code	CPT 26750
Hospital Charge Code	8026750
Hospital Revenue Code	521
Min. Negotiated Rate	$415.80
Max. Negotiated Rate	$594.00
Rate for Payer: Aetna Commercial	$564.30
Rate for Payer: Aetna Medicare	$534.60
Rate for Payer: BCBS MT CHIP	$534.60
Rate for Payer: BCBS MT Closed Plan Network	$564.30
Rate for Payer: BCBS MT HealthLink	$534.60
Rate for Payer: BCBS MT Medicare	$534.60
Rate for Payer: BCBS MT POS	$564.30
Rate for Payer: BCBS MT Traditional	$594.00
Rate for Payer: Cash Price	$534.60
Rate for Payer: Cigna Commercial	$564.30
Rate for Payer: Cigna Medicare	$534.60
Rate for Payer: Medicaid All Medicaid	$546.48
Rate for Payer: Medicare All Medicare	$415.80
Rate for Payer: Monida Allegiance	$564.30
Rate for Payer: Monida First Choice Health	$576.18
Rate for Payer: Monida Montana Health Co-op	$564.30
Rate for Payer: Monida PacificSource	$564.30

FX CLOSED DISTAL PHLANG W/O MANIPULATION

Facility

$594.00

Service Code	CPT 26750
Hospital Charge Code	8026750
Hospital Revenue Code	521
Min. Negotiated Rate	$415.80
Max. Negotiated Rate	$594.00
Rate for Payer: Aetna Commercial	$564.30
Rate for Payer: Aetna Medicare	$534.60
Rate for Payer: BCBS MT CHIP	$534.60
Rate for Payer: BCBS MT Closed Plan Network	$564.30
Rate for Payer: BCBS MT HealthLink	$534.60
Rate for Payer: BCBS MT Medicare	$534.60
Rate for Payer: BCBS MT POS	$564.30
Rate for Payer: BCBS MT Traditional	$594.00
Rate for Payer: Cash Price	$534.60
Rate for Payer: Cigna Commercial	$564.30
Rate for Payer: Cigna Medicare	$534.60
Rate for Payer: Medicaid All Medicaid	$546.48
Rate for Payer: Medicare All Medicare	$415.80
Rate for Payer: Monida Allegiance	$564.30
Rate for Payer: Monida First Choice Health	$576.18
Rate for Payer: Monida Montana Health Co-op	$564.30
Rate for Payer: Monida PacificSource	$564.30

FX CLOSED DISTAL RADIAL WITH MANIPUL

Facility

$930.00

Service Code	CPT 25605
Hospital Charge Code	1025605
Hospital Revenue Code	450
Min. Negotiated Rate	$651.00
Max. Negotiated Rate	$930.00
Rate for Payer: Aetna Commercial	$883.50
Rate for Payer: Aetna Medicare	$837.00
Rate for Payer: BCBS MT CHIP	$837.00
Rate for Payer: BCBS MT Closed Plan Network	$883.50
Rate for Payer: BCBS MT HealthLink	$837.00
Rate for Payer: BCBS MT Medicare	$837.00
Rate for Payer: BCBS MT POS	$883.50
Rate for Payer: BCBS MT Traditional	$930.00
Rate for Payer: Cash Price	$837.00
Rate for Payer: Cigna Commercial	$883.50
Rate for Payer: Cigna Medicare	$837.00
Rate for Payer: Medicaid All Medicaid	$855.60
Rate for Payer: Medicare All Medicare	$651.00
Rate for Payer: Monida Allegiance	$883.50
Rate for Payer: Monida First Choice Health	$902.10
Rate for Payer: Monida Montana Health Co-op	$883.50
Rate for Payer: Monida PacificSource	$883.50

FX CLOSED DISTAL RADIAL WITH MANIPUL

Facility

$930.00

Service Code	CPT 25605
Hospital Charge Code	1025605
Hospital Revenue Code	450
Min. Negotiated Rate	$651.00
Max. Negotiated Rate	$930.00
Rate for Payer: Aetna Commercial	$883.50
Rate for Payer: Aetna Medicare	$837.00
Rate for Payer: BCBS MT CHIP	$837.00
Rate for Payer: BCBS MT Closed Plan Network	$883.50
Rate for Payer: BCBS MT HealthLink	$837.00
Rate for Payer: BCBS MT Medicare	$837.00
Rate for Payer: BCBS MT POS	$883.50
Rate for Payer: BCBS MT Traditional	$930.00
Rate for Payer: Cash Price	$837.00
Rate for Payer: Cigna Commercial	$883.50
Rate for Payer: Cigna Medicare	$837.00
Rate for Payer: Medicaid All Medicaid	$855.60
Rate for Payer: Medicare All Medicare	$651.00
Rate for Payer: Monida Allegiance	$883.50
Rate for Payer: Monida First Choice Health	$902.10
Rate for Payer: Monida Montana Health Co-op	$883.50
Rate for Payer: Monida PacificSource	$883.50

Know your out-of-pocket cost for care.

All Charges