Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

FX CLOSED DISTAL RADIAL W/O MANIPUL

Facility

$652.00

Service Code	CPT 25600
Hospital Charge Code	8025600
Hospital Revenue Code	521
Min. Negotiated Rate	$456.40
Max. Negotiated Rate	$652.00
Rate for Payer: Aetna Commercial	$619.40
Rate for Payer: Aetna Medicare	$586.80
Rate for Payer: BCBS MT CHIP	$586.80
Rate for Payer: BCBS MT Closed Plan Network	$619.40
Rate for Payer: BCBS MT HealthLink	$586.80
Rate for Payer: BCBS MT Medicare	$586.80
Rate for Payer: BCBS MT POS	$619.40
Rate for Payer: BCBS MT Traditional	$652.00
Rate for Payer: Cash Price	$586.80
Rate for Payer: Cigna Commercial	$619.40
Rate for Payer: Cigna Medicare	$586.80
Rate for Payer: Medicaid All Medicaid	$599.84
Rate for Payer: Medicare All Medicare	$456.40
Rate for Payer: Monida Allegiance	$619.40
Rate for Payer: Monida First Choice Health	$632.44
Rate for Payer: Monida Montana Health Co-op	$619.40
Rate for Payer: Monida PacificSource	$619.40

FX CLOSED DISTAL RADIAL W/O MANIPUL

Facility

$652.00

Service Code	CPT 25600
Hospital Charge Code	8025600
Hospital Revenue Code	521
Min. Negotiated Rate	$456.40
Max. Negotiated Rate	$652.00
Rate for Payer: Aetna Commercial	$619.40
Rate for Payer: Aetna Medicare	$586.80
Rate for Payer: BCBS MT CHIP	$586.80
Rate for Payer: BCBS MT Closed Plan Network	$619.40
Rate for Payer: BCBS MT HealthLink	$586.80
Rate for Payer: BCBS MT Medicare	$586.80
Rate for Payer: BCBS MT POS	$619.40
Rate for Payer: BCBS MT Traditional	$652.00
Rate for Payer: Cash Price	$586.80
Rate for Payer: Cigna Commercial	$619.40
Rate for Payer: Cigna Medicare	$586.80
Rate for Payer: Medicaid All Medicaid	$599.84
Rate for Payer: Medicare All Medicare	$456.40
Rate for Payer: Monida Allegiance	$619.40
Rate for Payer: Monida First Choice Health	$632.44
Rate for Payer: Monida Montana Health Co-op	$619.40
Rate for Payer: Monida PacificSource	$619.40

FX CLOSED FIBULA PROXIMAL/SHAFT W/O MAN

Facility

$695.00

Service Code	CPT 27780
Hospital Charge Code	8027780
Hospital Revenue Code	521
Min. Negotiated Rate	$486.50
Max. Negotiated Rate	$695.00
Rate for Payer: Aetna Commercial	$660.25
Rate for Payer: Aetna Medicare	$625.50
Rate for Payer: BCBS MT CHIP	$625.50
Rate for Payer: BCBS MT Closed Plan Network	$660.25
Rate for Payer: BCBS MT HealthLink	$625.50
Rate for Payer: BCBS MT Medicare	$625.50
Rate for Payer: BCBS MT POS	$660.25
Rate for Payer: BCBS MT Traditional	$695.00
Rate for Payer: Cash Price	$625.50
Rate for Payer: Cigna Commercial	$660.25
Rate for Payer: Cigna Medicare	$625.50
Rate for Payer: Medicaid All Medicaid	$639.40
Rate for Payer: Medicare All Medicare	$486.50
Rate for Payer: Monida Allegiance	$660.25
Rate for Payer: Monida First Choice Health	$674.15
Rate for Payer: Monida Montana Health Co-op	$660.25
Rate for Payer: Monida PacificSource	$660.25

FX CLOSED FIBULA PROXIMAL/SHAFT W/O MAN

Facility

$695.00

Service Code	CPT 27780
Hospital Charge Code	8027780
Hospital Revenue Code	521
Min. Negotiated Rate	$486.50
Max. Negotiated Rate	$695.00
Rate for Payer: Aetna Commercial	$660.25
Rate for Payer: Aetna Medicare	$625.50
Rate for Payer: BCBS MT CHIP	$625.50
Rate for Payer: BCBS MT Closed Plan Network	$660.25
Rate for Payer: BCBS MT HealthLink	$625.50
Rate for Payer: BCBS MT Medicare	$625.50
Rate for Payer: BCBS MT POS	$660.25
Rate for Payer: BCBS MT Traditional	$695.00
Rate for Payer: Cash Price	$625.50
Rate for Payer: Cigna Commercial	$660.25
Rate for Payer: Cigna Medicare	$625.50
Rate for Payer: Medicaid All Medicaid	$639.40
Rate for Payer: Medicare All Medicare	$486.50
Rate for Payer: Monida Allegiance	$660.25
Rate for Payer: Monida First Choice Health	$674.15
Rate for Payer: Monida Montana Health Co-op	$660.25
Rate for Payer: Monida PacificSource	$660.25

FX CLOSED METACARPAL SINGLE W/O MANIPUL

Facility

$563.00

Service Code	CPT 26600
Hospital Charge Code	8026600
Hospital Revenue Code	521
Min. Negotiated Rate	$394.10
Max. Negotiated Rate	$563.00
Rate for Payer: Aetna Commercial	$534.85
Rate for Payer: Aetna Medicare	$506.70
Rate for Payer: BCBS MT CHIP	$506.70
Rate for Payer: BCBS MT Closed Plan Network	$534.85
Rate for Payer: BCBS MT HealthLink	$506.70
Rate for Payer: BCBS MT Medicare	$506.70
Rate for Payer: BCBS MT POS	$534.85
Rate for Payer: BCBS MT Traditional	$563.00
Rate for Payer: Cash Price	$506.70
Rate for Payer: Cigna Commercial	$534.85
Rate for Payer: Cigna Medicare	$506.70
Rate for Payer: Medicaid All Medicaid	$517.96
Rate for Payer: Medicare All Medicare	$394.10
Rate for Payer: Monida Allegiance	$534.85
Rate for Payer: Monida First Choice Health	$546.11
Rate for Payer: Monida Montana Health Co-op	$534.85
Rate for Payer: Monida PacificSource	$534.85

FX CLOSED METACARPAL SINGLE W/O MANIPUL

Facility

$563.00

Service Code	CPT 26600
Hospital Charge Code	8026600
Hospital Revenue Code	521
Min. Negotiated Rate	$394.10
Max. Negotiated Rate	$563.00
Rate for Payer: Aetna Commercial	$534.85
Rate for Payer: Aetna Medicare	$506.70
Rate for Payer: BCBS MT CHIP	$506.70
Rate for Payer: BCBS MT Closed Plan Network	$534.85
Rate for Payer: BCBS MT HealthLink	$506.70
Rate for Payer: BCBS MT Medicare	$506.70
Rate for Payer: BCBS MT POS	$534.85
Rate for Payer: BCBS MT Traditional	$563.00
Rate for Payer: Cash Price	$506.70
Rate for Payer: Cigna Commercial	$534.85
Rate for Payer: Cigna Medicare	$506.70
Rate for Payer: Medicaid All Medicaid	$517.96
Rate for Payer: Medicare All Medicare	$394.10
Rate for Payer: Monida Allegiance	$534.85
Rate for Payer: Monida First Choice Health	$546.11
Rate for Payer: Monida Montana Health Co-op	$534.85
Rate for Payer: Monida PacificSource	$534.85

FX CLOSED METATARSAL W/O MANIPULATION

Facility

$585.00

Service Code	CPT 28470
Hospital Charge Code	8028470
Hospital Revenue Code	521
Min. Negotiated Rate	$409.50
Max. Negotiated Rate	$585.00
Rate for Payer: Aetna Commercial	$555.75
Rate for Payer: Aetna Medicare	$526.50
Rate for Payer: BCBS MT CHIP	$526.50
Rate for Payer: BCBS MT Closed Plan Network	$555.75
Rate for Payer: BCBS MT HealthLink	$526.50
Rate for Payer: BCBS MT Medicare	$526.50
Rate for Payer: BCBS MT POS	$555.75
Rate for Payer: BCBS MT Traditional	$585.00
Rate for Payer: Cash Price	$526.50
Rate for Payer: Cigna Commercial	$555.75
Rate for Payer: Cigna Medicare	$526.50
Rate for Payer: Medicaid All Medicaid	$538.20
Rate for Payer: Medicare All Medicare	$409.50
Rate for Payer: Monida Allegiance	$555.75
Rate for Payer: Monida First Choice Health	$567.45
Rate for Payer: Monida Montana Health Co-op	$555.75
Rate for Payer: Monida PacificSource	$555.75

FX CLOSED METATARSAL W/O MANIPULATION

Facility

$585.00

Service Code	CPT 28470
Hospital Charge Code	8028470
Hospital Revenue Code	521
Min. Negotiated Rate	$409.50
Max. Negotiated Rate	$585.00
Rate for Payer: Aetna Commercial	$555.75
Rate for Payer: Aetna Medicare	$526.50
Rate for Payer: BCBS MT CHIP	$526.50
Rate for Payer: BCBS MT Closed Plan Network	$555.75
Rate for Payer: BCBS MT HealthLink	$526.50
Rate for Payer: BCBS MT Medicare	$526.50
Rate for Payer: BCBS MT POS	$555.75
Rate for Payer: BCBS MT Traditional	$585.00
Rate for Payer: Cash Price	$526.50
Rate for Payer: Cigna Commercial	$555.75
Rate for Payer: Cigna Medicare	$526.50
Rate for Payer: Medicaid All Medicaid	$538.20
Rate for Payer: Medicare All Medicare	$409.50
Rate for Payer: Monida Allegiance	$555.75
Rate for Payer: Monida First Choice Health	$567.45
Rate for Payer: Monida Montana Health Co-op	$555.75
Rate for Payer: Monida PacificSource	$555.75

FX CLOSED PATELLA/KNEE CAP

Facility

$585.00

Service Code	CPT 27520
Hospital Charge Code	8027520
Hospital Revenue Code	521
Min. Negotiated Rate	$409.50
Max. Negotiated Rate	$585.00
Rate for Payer: Aetna Commercial	$555.75
Rate for Payer: Aetna Medicare	$526.50
Rate for Payer: BCBS MT CHIP	$526.50
Rate for Payer: BCBS MT Closed Plan Network	$555.75
Rate for Payer: BCBS MT HealthLink	$526.50
Rate for Payer: BCBS MT Medicare	$526.50
Rate for Payer: BCBS MT POS	$555.75
Rate for Payer: BCBS MT Traditional	$585.00
Rate for Payer: Cash Price	$526.50
Rate for Payer: Cigna Commercial	$555.75
Rate for Payer: Cigna Medicare	$526.50
Rate for Payer: Medicaid All Medicaid	$538.20
Rate for Payer: Medicare All Medicare	$409.50
Rate for Payer: Monida Allegiance	$555.75
Rate for Payer: Monida First Choice Health	$567.45
Rate for Payer: Monida Montana Health Co-op	$555.75
Rate for Payer: Monida PacificSource	$555.75

FX CLOSED PATELLA/KNEE CAP

Facility

$585.00

Service Code	CPT 27520
Hospital Charge Code	8027520
Hospital Revenue Code	521
Min. Negotiated Rate	$409.50
Max. Negotiated Rate	$585.00
Rate for Payer: Aetna Commercial	$555.75
Rate for Payer: Aetna Medicare	$526.50
Rate for Payer: BCBS MT CHIP	$526.50
Rate for Payer: BCBS MT Closed Plan Network	$555.75
Rate for Payer: BCBS MT HealthLink	$526.50
Rate for Payer: BCBS MT Medicare	$526.50
Rate for Payer: BCBS MT POS	$555.75
Rate for Payer: BCBS MT Traditional	$585.00
Rate for Payer: Cash Price	$526.50
Rate for Payer: Cigna Commercial	$555.75
Rate for Payer: Cigna Medicare	$526.50
Rate for Payer: Medicaid All Medicaid	$538.20
Rate for Payer: Medicare All Medicare	$409.50
Rate for Payer: Monida Allegiance	$555.75
Rate for Payer: Monida First Choice Health	$567.45
Rate for Payer: Monida Montana Health Co-op	$555.75
Rate for Payer: Monida PacificSource	$555.75

FX CLOSED PHALAN/PROX/MIDDLE W/O MANIPUL

Facility

$534.00

Service Code	CPT 26720
Hospital Charge Code	8026720
Hospital Revenue Code	521
Min. Negotiated Rate	$373.80
Max. Negotiated Rate	$534.00
Rate for Payer: Aetna Commercial	$507.30
Rate for Payer: Aetna Medicare	$480.60
Rate for Payer: BCBS MT CHIP	$480.60
Rate for Payer: BCBS MT Closed Plan Network	$507.30
Rate for Payer: BCBS MT HealthLink	$480.60
Rate for Payer: BCBS MT Medicare	$480.60
Rate for Payer: BCBS MT POS	$507.30
Rate for Payer: BCBS MT Traditional	$534.00
Rate for Payer: Cash Price	$480.60
Rate for Payer: Cigna Commercial	$507.30
Rate for Payer: Cigna Medicare	$480.60
Rate for Payer: Medicaid All Medicaid	$491.28
Rate for Payer: Medicare All Medicare	$373.80
Rate for Payer: Monida Allegiance	$507.30
Rate for Payer: Monida First Choice Health	$517.98
Rate for Payer: Monida Montana Health Co-op	$507.30
Rate for Payer: Monida PacificSource	$507.30

FX CLOSED PHALAN/PROX/MIDDLE W/O MANIPUL

Facility

$534.00

Service Code	CPT 26720
Hospital Charge Code	8026720
Hospital Revenue Code	521
Min. Negotiated Rate	$373.80
Max. Negotiated Rate	$534.00
Rate for Payer: Aetna Commercial	$507.30
Rate for Payer: Aetna Medicare	$480.60
Rate for Payer: BCBS MT CHIP	$480.60
Rate for Payer: BCBS MT Closed Plan Network	$507.30
Rate for Payer: BCBS MT HealthLink	$480.60
Rate for Payer: BCBS MT Medicare	$480.60
Rate for Payer: BCBS MT POS	$507.30
Rate for Payer: BCBS MT Traditional	$534.00
Rate for Payer: Cash Price	$480.60
Rate for Payer: Cigna Commercial	$507.30
Rate for Payer: Cigna Medicare	$480.60
Rate for Payer: Medicaid All Medicaid	$491.28
Rate for Payer: Medicare All Medicare	$373.80
Rate for Payer: Monida Allegiance	$507.30
Rate for Payer: Monida First Choice Health	$517.98
Rate for Payer: Monida Montana Health Co-op	$507.30
Rate for Payer: Monida PacificSource	$507.30

FX CLOSED RADIAL SHAFT W/O MANIPUL

Facility

$549.00

Service Code	CPT 25500
Hospital Charge Code	8025500
Hospital Revenue Code	521
Min. Negotiated Rate	$384.30
Max. Negotiated Rate	$549.00
Rate for Payer: Aetna Commercial	$521.55
Rate for Payer: Aetna Medicare	$494.10
Rate for Payer: BCBS MT CHIP	$494.10
Rate for Payer: BCBS MT Closed Plan Network	$521.55
Rate for Payer: BCBS MT HealthLink	$494.10
Rate for Payer: BCBS MT Medicare	$494.10
Rate for Payer: BCBS MT POS	$521.55
Rate for Payer: BCBS MT Traditional	$549.00
Rate for Payer: Cash Price	$494.10
Rate for Payer: Cigna Commercial	$521.55
Rate for Payer: Cigna Medicare	$494.10
Rate for Payer: Medicaid All Medicaid	$505.08
Rate for Payer: Medicare All Medicare	$384.30
Rate for Payer: Monida Allegiance	$521.55
Rate for Payer: Monida First Choice Health	$532.53
Rate for Payer: Monida Montana Health Co-op	$521.55
Rate for Payer: Monida PacificSource	$521.55

FX CLOSED RADIAL SHAFT W/O MANIPUL

Facility

$549.00

Service Code	CPT 25500
Hospital Charge Code	8025500
Hospital Revenue Code	521
Min. Negotiated Rate	$384.30
Max. Negotiated Rate	$549.00
Rate for Payer: Aetna Commercial	$521.55
Rate for Payer: Aetna Medicare	$494.10
Rate for Payer: BCBS MT CHIP	$494.10
Rate for Payer: BCBS MT Closed Plan Network	$521.55
Rate for Payer: BCBS MT HealthLink	$494.10
Rate for Payer: BCBS MT Medicare	$494.10
Rate for Payer: BCBS MT POS	$521.55
Rate for Payer: BCBS MT Traditional	$549.00
Rate for Payer: Cash Price	$494.10
Rate for Payer: Cigna Commercial	$521.55
Rate for Payer: Cigna Medicare	$494.10
Rate for Payer: Medicaid All Medicaid	$505.08
Rate for Payer: Medicare All Medicare	$384.30
Rate for Payer: Monida Allegiance	$521.55
Rate for Payer: Monida First Choice Health	$532.53
Rate for Payer: Monida Montana Health Co-op	$521.55
Rate for Payer: Monida PacificSource	$521.55

FX CLOSED TARSAL W/O MANIPULATION

Facility

$617.00

Service Code	CPT 28450
Hospital Charge Code	8028450
Hospital Revenue Code	521
Min. Negotiated Rate	$431.90
Max. Negotiated Rate	$617.00
Rate for Payer: Aetna Commercial	$586.15
Rate for Payer: Aetna Medicare	$555.30
Rate for Payer: BCBS MT CHIP	$555.30
Rate for Payer: BCBS MT Closed Plan Network	$586.15
Rate for Payer: BCBS MT HealthLink	$555.30
Rate for Payer: BCBS MT Medicare	$555.30
Rate for Payer: BCBS MT POS	$586.15
Rate for Payer: BCBS MT Traditional	$617.00
Rate for Payer: Cash Price	$555.30
Rate for Payer: Cigna Commercial	$586.15
Rate for Payer: Cigna Medicare	$555.30
Rate for Payer: Medicaid All Medicaid	$567.64
Rate for Payer: Medicare All Medicare	$431.90
Rate for Payer: Monida Allegiance	$586.15
Rate for Payer: Monida First Choice Health	$598.49
Rate for Payer: Monida Montana Health Co-op	$586.15
Rate for Payer: Monida PacificSource	$586.15

FX CLOSED TARSAL W/O MANIPULATION

Facility

$617.00

Service Code	CPT 28450
Hospital Charge Code	8028450
Hospital Revenue Code	521
Min. Negotiated Rate	$431.90
Max. Negotiated Rate	$617.00
Rate for Payer: Aetna Commercial	$586.15
Rate for Payer: Aetna Medicare	$555.30
Rate for Payer: BCBS MT CHIP	$555.30
Rate for Payer: BCBS MT Closed Plan Network	$586.15
Rate for Payer: BCBS MT HealthLink	$555.30
Rate for Payer: BCBS MT Medicare	$555.30
Rate for Payer: BCBS MT POS	$586.15
Rate for Payer: BCBS MT Traditional	$617.00
Rate for Payer: Cash Price	$555.30
Rate for Payer: Cigna Commercial	$586.15
Rate for Payer: Cigna Medicare	$555.30
Rate for Payer: Medicaid All Medicaid	$567.64
Rate for Payer: Medicare All Medicare	$431.90
Rate for Payer: Monida Allegiance	$586.15
Rate for Payer: Monida First Choice Health	$598.49
Rate for Payer: Monida Montana Health Co-op	$586.15
Rate for Payer: Monida PacificSource	$586.15

FX CLOSED TIBIAL PROXIMAL PLATEAU

Facility

$869.00

Service Code	CPT 27530
Hospital Charge Code	8027530
Hospital Revenue Code	521
Min. Negotiated Rate	$608.30
Max. Negotiated Rate	$869.00
Rate for Payer: Aetna Commercial	$825.55
Rate for Payer: Aetna Medicare	$782.10
Rate for Payer: BCBS MT CHIP	$782.10
Rate for Payer: BCBS MT Closed Plan Network	$825.55
Rate for Payer: BCBS MT HealthLink	$782.10
Rate for Payer: BCBS MT Medicare	$782.10
Rate for Payer: BCBS MT POS	$825.55
Rate for Payer: BCBS MT Traditional	$869.00
Rate for Payer: Cash Price	$782.10
Rate for Payer: Cigna Commercial	$825.55
Rate for Payer: Cigna Medicare	$782.10
Rate for Payer: Medicaid All Medicaid	$799.48
Rate for Payer: Medicare All Medicare	$608.30
Rate for Payer: Monida Allegiance	$825.55
Rate for Payer: Monida First Choice Health	$842.93
Rate for Payer: Monida Montana Health Co-op	$825.55
Rate for Payer: Monida PacificSource	$825.55

FX CLOSED TIBIAL PROXIMAL PLATEAU

Facility

$869.00

Service Code	CPT 27530
Hospital Charge Code	8027530
Hospital Revenue Code	521
Min. Negotiated Rate	$608.30
Max. Negotiated Rate	$869.00
Rate for Payer: Aetna Commercial	$825.55
Rate for Payer: Aetna Medicare	$782.10
Rate for Payer: BCBS MT CHIP	$782.10
Rate for Payer: BCBS MT Closed Plan Network	$825.55
Rate for Payer: BCBS MT HealthLink	$782.10
Rate for Payer: BCBS MT Medicare	$782.10
Rate for Payer: BCBS MT POS	$825.55
Rate for Payer: BCBS MT Traditional	$869.00
Rate for Payer: Cash Price	$782.10
Rate for Payer: Cigna Commercial	$825.55
Rate for Payer: Cigna Medicare	$782.10
Rate for Payer: Medicaid All Medicaid	$799.48
Rate for Payer: Medicare All Medicare	$608.30
Rate for Payer: Monida Allegiance	$825.55
Rate for Payer: Monida First Choice Health	$842.93
Rate for Payer: Monida Montana Health Co-op	$825.55
Rate for Payer: Monida PacificSource	$825.55

FX CLOSED TIBIA SHAFT W/O MANIPULA

Facility

$872.00

Service Code	CPT 27750
Hospital Charge Code	8027750
Hospital Revenue Code	521
Min. Negotiated Rate	$610.40
Max. Negotiated Rate	$872.00
Rate for Payer: Aetna Commercial	$828.40
Rate for Payer: Aetna Medicare	$784.80
Rate for Payer: BCBS MT CHIP	$784.80
Rate for Payer: BCBS MT Closed Plan Network	$828.40
Rate for Payer: BCBS MT HealthLink	$784.80
Rate for Payer: BCBS MT Medicare	$784.80
Rate for Payer: BCBS MT POS	$828.40
Rate for Payer: BCBS MT Traditional	$872.00
Rate for Payer: Cash Price	$784.80
Rate for Payer: Cigna Commercial	$828.40
Rate for Payer: Cigna Medicare	$784.80
Rate for Payer: Medicaid All Medicaid	$802.24
Rate for Payer: Medicare All Medicare	$610.40
Rate for Payer: Monida Allegiance	$828.40
Rate for Payer: Monida First Choice Health	$845.84
Rate for Payer: Monida Montana Health Co-op	$828.40
Rate for Payer: Monida PacificSource	$828.40

FX CLOSED TIBIA SHAFT W/O MANIPULA

Facility

$872.00

Service Code	CPT 27750
Hospital Charge Code	8027750
Hospital Revenue Code	521
Min. Negotiated Rate	$610.40
Max. Negotiated Rate	$872.00
Rate for Payer: Aetna Commercial	$828.40
Rate for Payer: Aetna Medicare	$784.80
Rate for Payer: BCBS MT CHIP	$784.80
Rate for Payer: BCBS MT Closed Plan Network	$828.40
Rate for Payer: BCBS MT HealthLink	$784.80
Rate for Payer: BCBS MT Medicare	$784.80
Rate for Payer: BCBS MT POS	$828.40
Rate for Payer: BCBS MT Traditional	$872.00
Rate for Payer: Cash Price	$784.80
Rate for Payer: Cigna Commercial	$828.40
Rate for Payer: Cigna Medicare	$784.80
Rate for Payer: Medicaid All Medicaid	$802.24
Rate for Payer: Medicare All Medicare	$610.40
Rate for Payer: Monida Allegiance	$828.40
Rate for Payer: Monida First Choice Health	$845.84
Rate for Payer: Monida Montana Health Co-op	$828.40
Rate for Payer: Monida PacificSource	$828.40

G6PD ENZYME ACTIVITY (121003)

Facility

$82.00

Service Code	CPT 82955
Hospital Charge Code	4082955
Hospital Revenue Code	301
Min. Negotiated Rate	$57.40
Max. Negotiated Rate	$82.00
Rate for Payer: Aetna Commercial	$77.90
Rate for Payer: Aetna Medicare	$73.80
Rate for Payer: BCBS MT CHIP	$73.80
Rate for Payer: BCBS MT Closed Plan Network	$77.90
Rate for Payer: BCBS MT HealthLink	$73.80
Rate for Payer: BCBS MT Medicare	$73.80
Rate for Payer: BCBS MT POS	$77.90
Rate for Payer: BCBS MT Traditional	$82.00
Rate for Payer: Cash Price	$73.80
Rate for Payer: Cigna Commercial	$77.90
Rate for Payer: Cigna Medicare	$73.80
Rate for Payer: Medicaid All Medicaid	$75.44
Rate for Payer: Medicare All Medicare	$57.40
Rate for Payer: Monida Allegiance	$77.90
Rate for Payer: Monida First Choice Health	$79.54
Rate for Payer: Monida Montana Health Co-op	$77.90
Rate for Payer: Monida PacificSource	$77.90

G6PD ENZYME ACTIVITY (121003)

Facility

$82.00

Service Code	CPT 82955
Hospital Charge Code	4082955
Hospital Revenue Code	301
Min. Negotiated Rate	$57.40
Max. Negotiated Rate	$82.00
Rate for Payer: Aetna Commercial	$77.90
Rate for Payer: Aetna Medicare	$73.80
Rate for Payer: BCBS MT CHIP	$73.80
Rate for Payer: BCBS MT Closed Plan Network	$77.90
Rate for Payer: BCBS MT HealthLink	$73.80
Rate for Payer: BCBS MT Medicare	$73.80
Rate for Payer: BCBS MT POS	$77.90
Rate for Payer: BCBS MT Traditional	$82.00
Rate for Payer: Cash Price	$73.80
Rate for Payer: Cigna Commercial	$77.90
Rate for Payer: Cigna Medicare	$73.80
Rate for Payer: Medicaid All Medicaid	$75.44
Rate for Payer: Medicare All Medicare	$57.40
Rate for Payer: Monida Allegiance	$77.90
Rate for Payer: Monida First Choice Health	$79.54
Rate for Payer: Monida Montana Health Co-op	$77.90
Rate for Payer: Monida PacificSource	$77.90

GABAPENTIN CAP [100 MG]

Facility

$8.00

Service Code	HCPCS J8499
Hospital Charge Code	3000195
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

GABAPENTIN CAP [100 MG]

Facility

$8.00

Service Code	HCPCS J8499
Hospital Charge Code	3000195
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

GABAPENTIN CAP [300 MG]

Facility

$8.00

Service Code	HCPCS J8499
Hospital Charge Code	3000196
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

Know your out-of-pocket cost for care.

All Charges