Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

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

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

Know your out-of-pocket cost for care.

All Charges