Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

HIV AG/AB COMBO W/ REFLEX (083935)

Facility

$84.00

Service Code	CPT 87389
Hospital Charge Code	4087389
Hospital Revenue Code	300
Min. Negotiated Rate	$58.80
Max. Negotiated Rate	$84.00
Rate for Payer: Aetna Commercial	$79.80
Rate for Payer: Aetna Medicare	$75.60
Rate for Payer: BCBS MT CHIP	$75.60
Rate for Payer: BCBS MT Closed Plan Network	$79.80
Rate for Payer: BCBS MT HealthLink	$75.60
Rate for Payer: BCBS MT Medicare	$75.60
Rate for Payer: BCBS MT POS	$79.80
Rate for Payer: BCBS MT Traditional	$84.00
Rate for Payer: Cash Price	$75.60
Rate for Payer: Cigna Commercial	$79.80
Rate for Payer: Cigna Medicare	$75.60
Rate for Payer: Medicaid All Medicaid	$77.28
Rate for Payer: Medicare All Medicare	$58.80
Rate for Payer: Monida Allegiance	$79.80
Rate for Payer: Monida First Choice Health	$81.48
Rate for Payer: Monida Montana Health Co-op	$79.80
Rate for Payer: Monida PacificSource	$79.80

HIV AG/AB COMBO W/ REFLEX (083935)

Facility

$84.00

Service Code	CPT 87389
Hospital Charge Code	4087389
Hospital Revenue Code	300
Min. Negotiated Rate	$58.80
Max. Negotiated Rate	$84.00
Rate for Payer: Aetna Commercial	$79.80
Rate for Payer: Aetna Medicare	$75.60
Rate for Payer: BCBS MT CHIP	$75.60
Rate for Payer: BCBS MT Closed Plan Network	$79.80
Rate for Payer: BCBS MT HealthLink	$75.60
Rate for Payer: BCBS MT Medicare	$75.60
Rate for Payer: BCBS MT POS	$79.80
Rate for Payer: BCBS MT Traditional	$84.00
Rate for Payer: Cash Price	$75.60
Rate for Payer: Cigna Commercial	$79.80
Rate for Payer: Cigna Medicare	$75.60
Rate for Payer: Medicaid All Medicaid	$77.28
Rate for Payer: Medicare All Medicare	$58.80
Rate for Payer: Monida Allegiance	$79.80
Rate for Payer: Monida First Choice Health	$81.48
Rate for Payer: Monida Montana Health Co-op	$79.80
Rate for Payer: Monida PacificSource	$79.80

HIV I/II DIFFERENTIATION

Facility

$95.00

Service Code	CPT 86701
Hospital Charge Code	4088090
Hospital Revenue Code	302
Min. Negotiated Rate	$66.50
Max. Negotiated Rate	$95.00
Rate for Payer: Aetna Commercial	$90.25
Rate for Payer: Aetna Medicare	$85.50
Rate for Payer: BCBS MT CHIP	$85.50
Rate for Payer: BCBS MT Closed Plan Network	$90.25
Rate for Payer: BCBS MT HealthLink	$85.50
Rate for Payer: BCBS MT Medicare	$85.50
Rate for Payer: BCBS MT POS	$90.25
Rate for Payer: BCBS MT Traditional	$95.00
Rate for Payer: Cash Price	$85.50
Rate for Payer: Cigna Commercial	$90.25
Rate for Payer: Cigna Medicare	$85.50
Rate for Payer: Medicaid All Medicaid	$87.40
Rate for Payer: Medicare All Medicare	$66.50
Rate for Payer: Monida Allegiance	$90.25
Rate for Payer: Monida First Choice Health	$92.15
Rate for Payer: Monida Montana Health Co-op	$90.25
Rate for Payer: Monida PacificSource	$90.25

HIV I/II DIFFERENTIATION

Facility

$95.00

Service Code	CPT 86701
Hospital Charge Code	4088090
Hospital Revenue Code	302
Min. Negotiated Rate	$66.50
Max. Negotiated Rate	$95.00
Rate for Payer: Aetna Commercial	$90.25
Rate for Payer: Aetna Medicare	$85.50
Rate for Payer: BCBS MT CHIP	$85.50
Rate for Payer: BCBS MT Closed Plan Network	$90.25
Rate for Payer: BCBS MT HealthLink	$85.50
Rate for Payer: BCBS MT Medicare	$85.50
Rate for Payer: BCBS MT POS	$90.25
Rate for Payer: BCBS MT Traditional	$95.00
Rate for Payer: Cash Price	$85.50
Rate for Payer: Cigna Commercial	$90.25
Rate for Payer: Cigna Medicare	$85.50
Rate for Payer: Medicaid All Medicaid	$87.40
Rate for Payer: Medicare All Medicare	$66.50
Rate for Payer: Monida Allegiance	$90.25
Rate for Payer: Monida First Choice Health	$92.15
Rate for Payer: Monida Montana Health Co-op	$90.25
Rate for Payer: Monida PacificSource	$90.25

HLA A GENOTYPE

Facility

$385.00

Service Code	CPT 81380
Hospital Charge Code	4088044
Hospital Revenue Code	302
Min. Negotiated Rate	$269.50
Max. Negotiated Rate	$385.00
Rate for Payer: Aetna Commercial	$365.75
Rate for Payer: Aetna Medicare	$346.50
Rate for Payer: BCBS MT CHIP	$346.50
Rate for Payer: BCBS MT Closed Plan Network	$365.75
Rate for Payer: BCBS MT HealthLink	$346.50
Rate for Payer: BCBS MT Medicare	$346.50
Rate for Payer: BCBS MT POS	$365.75
Rate for Payer: BCBS MT Traditional	$385.00
Rate for Payer: Cash Price	$346.50
Rate for Payer: Cigna Commercial	$365.75
Rate for Payer: Cigna Medicare	$346.50
Rate for Payer: Medicaid All Medicaid	$354.20
Rate for Payer: Medicare All Medicare	$269.50
Rate for Payer: Monida Allegiance	$365.75
Rate for Payer: Monida First Choice Health	$373.45
Rate for Payer: Monida Montana Health Co-op	$365.75
Rate for Payer: Monida PacificSource	$365.75

HLA A GENOTYPE

Facility

$385.00

Service Code	CPT 81380
Hospital Charge Code	4088044
Hospital Revenue Code	302
Min. Negotiated Rate	$269.50
Max. Negotiated Rate	$385.00
Rate for Payer: Aetna Commercial	$365.75
Rate for Payer: Aetna Medicare	$346.50
Rate for Payer: BCBS MT CHIP	$346.50
Rate for Payer: BCBS MT Closed Plan Network	$365.75
Rate for Payer: BCBS MT HealthLink	$346.50
Rate for Payer: BCBS MT Medicare	$346.50
Rate for Payer: BCBS MT POS	$365.75
Rate for Payer: BCBS MT Traditional	$385.00
Rate for Payer: Cash Price	$346.50
Rate for Payer: Cigna Commercial	$365.75
Rate for Payer: Cigna Medicare	$346.50
Rate for Payer: Medicaid All Medicaid	$354.20
Rate for Payer: Medicare All Medicare	$269.50
Rate for Payer: Monida Allegiance	$365.75
Rate for Payer: Monida First Choice Health	$373.45
Rate for Payer: Monida Montana Health Co-op	$365.75
Rate for Payer: Monida PacificSource	$365.75

HLA B27 DISEASE ASSOCIATION (006924)

Facility

$79.00

Service Code	CPT 81374
Hospital Charge Code	4081374
Hospital Revenue Code	302
Min. Negotiated Rate	$55.30
Max. Negotiated Rate	$79.00
Rate for Payer: Aetna Commercial	$75.05
Rate for Payer: Aetna Medicare	$71.10
Rate for Payer: BCBS MT CHIP	$71.10
Rate for Payer: BCBS MT Closed Plan Network	$75.05
Rate for Payer: BCBS MT HealthLink	$71.10
Rate for Payer: BCBS MT Medicare	$71.10
Rate for Payer: BCBS MT POS	$75.05
Rate for Payer: BCBS MT Traditional	$79.00
Rate for Payer: Cash Price	$71.10
Rate for Payer: Cigna Commercial	$75.05
Rate for Payer: Cigna Medicare	$71.10
Rate for Payer: Medicaid All Medicaid	$72.68
Rate for Payer: Medicare All Medicare	$55.30
Rate for Payer: Monida Allegiance	$75.05
Rate for Payer: Monida First Choice Health	$76.63
Rate for Payer: Monida Montana Health Co-op	$75.05
Rate for Payer: Monida PacificSource	$75.05

HLA B27 DISEASE ASSOCIATION (006924)

Facility

$79.00

Service Code	CPT 81374
Hospital Charge Code	4081374
Hospital Revenue Code	302
Min. Negotiated Rate	$55.30
Max. Negotiated Rate	$79.00
Rate for Payer: Aetna Commercial	$75.05
Rate for Payer: Aetna Medicare	$71.10
Rate for Payer: BCBS MT CHIP	$71.10
Rate for Payer: BCBS MT Closed Plan Network	$75.05
Rate for Payer: BCBS MT HealthLink	$71.10
Rate for Payer: BCBS MT Medicare	$71.10
Rate for Payer: BCBS MT POS	$75.05
Rate for Payer: BCBS MT Traditional	$79.00
Rate for Payer: Cash Price	$71.10
Rate for Payer: Cigna Commercial	$75.05
Rate for Payer: Cigna Medicare	$71.10
Rate for Payer: Medicaid All Medicaid	$72.68
Rate for Payer: Medicare All Medicare	$55.30
Rate for Payer: Monida Allegiance	$75.05
Rate for Payer: Monida First Choice Health	$76.63
Rate for Payer: Monida Montana Health Co-op	$75.05
Rate for Payer: Monida PacificSource	$75.05

HLA B GENOTYPE

Facility

$385.00

Service Code	CPT 81380
Hospital Charge Code	4088045
Hospital Revenue Code	302
Min. Negotiated Rate	$269.50
Max. Negotiated Rate	$385.00
Rate for Payer: Aetna Commercial	$365.75
Rate for Payer: Aetna Medicare	$346.50
Rate for Payer: BCBS MT CHIP	$346.50
Rate for Payer: BCBS MT Closed Plan Network	$365.75
Rate for Payer: BCBS MT HealthLink	$346.50
Rate for Payer: BCBS MT Medicare	$346.50
Rate for Payer: BCBS MT POS	$365.75
Rate for Payer: BCBS MT Traditional	$385.00
Rate for Payer: Cash Price	$346.50
Rate for Payer: Cigna Commercial	$365.75
Rate for Payer: Cigna Medicare	$346.50
Rate for Payer: Medicaid All Medicaid	$354.20
Rate for Payer: Medicare All Medicare	$269.50
Rate for Payer: Monida Allegiance	$365.75
Rate for Payer: Monida First Choice Health	$373.45
Rate for Payer: Monida Montana Health Co-op	$365.75
Rate for Payer: Monida PacificSource	$365.75

HLA B GENOTYPE

Facility

$385.00

Service Code	CPT 81380
Hospital Charge Code	4088045
Hospital Revenue Code	302
Min. Negotiated Rate	$269.50
Max. Negotiated Rate	$385.00
Rate for Payer: Aetna Commercial	$365.75
Rate for Payer: Aetna Medicare	$346.50
Rate for Payer: BCBS MT CHIP	$346.50
Rate for Payer: BCBS MT Closed Plan Network	$365.75
Rate for Payer: BCBS MT HealthLink	$346.50
Rate for Payer: BCBS MT Medicare	$346.50
Rate for Payer: BCBS MT POS	$365.75
Rate for Payer: BCBS MT Traditional	$385.00
Rate for Payer: Cash Price	$346.50
Rate for Payer: Cigna Commercial	$365.75
Rate for Payer: Cigna Medicare	$346.50
Rate for Payer: Medicaid All Medicaid	$354.20
Rate for Payer: Medicare All Medicare	$269.50
Rate for Payer: Monida Allegiance	$365.75
Rate for Payer: Monida First Choice Health	$373.45
Rate for Payer: Monida Montana Health Co-op	$365.75
Rate for Payer: Monida PacificSource	$365.75

HLA C GENOTYPE

Facility

$385.00

Service Code	CPT 81380
Hospital Charge Code	4088046
Hospital Revenue Code	302
Min. Negotiated Rate	$269.50
Max. Negotiated Rate	$385.00
Rate for Payer: Aetna Commercial	$365.75
Rate for Payer: Aetna Medicare	$346.50
Rate for Payer: BCBS MT CHIP	$346.50
Rate for Payer: BCBS MT Closed Plan Network	$365.75
Rate for Payer: BCBS MT HealthLink	$346.50
Rate for Payer: BCBS MT Medicare	$346.50
Rate for Payer: BCBS MT POS	$365.75
Rate for Payer: BCBS MT Traditional	$385.00
Rate for Payer: Cash Price	$346.50
Rate for Payer: Cigna Commercial	$365.75
Rate for Payer: Cigna Medicare	$346.50
Rate for Payer: Medicaid All Medicaid	$354.20
Rate for Payer: Medicare All Medicare	$269.50
Rate for Payer: Monida Allegiance	$365.75
Rate for Payer: Monida First Choice Health	$373.45
Rate for Payer: Monida Montana Health Co-op	$365.75
Rate for Payer: Monida PacificSource	$365.75

HLA C GENOTYPE

Facility

$385.00

Service Code	CPT 81380
Hospital Charge Code	4088046
Hospital Revenue Code	302
Min. Negotiated Rate	$269.50
Max. Negotiated Rate	$385.00
Rate for Payer: Aetna Commercial	$365.75
Rate for Payer: Aetna Medicare	$346.50
Rate for Payer: BCBS MT CHIP	$346.50
Rate for Payer: BCBS MT Closed Plan Network	$365.75
Rate for Payer: BCBS MT HealthLink	$346.50
Rate for Payer: BCBS MT Medicare	$346.50
Rate for Payer: BCBS MT POS	$365.75
Rate for Payer: BCBS MT Traditional	$385.00
Rate for Payer: Cash Price	$346.50
Rate for Payer: Cigna Commercial	$365.75
Rate for Payer: Cigna Medicare	$346.50
Rate for Payer: Medicaid All Medicaid	$354.20
Rate for Payer: Medicare All Medicare	$269.50
Rate for Payer: Monida Allegiance	$365.75
Rate for Payer: Monida First Choice Health	$373.45
Rate for Payer: Monida Montana Health Co-op	$365.75
Rate for Payer: Monida PacificSource	$365.75

HLA DR GENOTYPING

Facility

$415.00

Service Code	CPT 81382
Hospital Charge Code	4088047
Hospital Revenue Code	302
Min. Negotiated Rate	$290.50
Max. Negotiated Rate	$415.00
Rate for Payer: Aetna Commercial	$394.25
Rate for Payer: Aetna Medicare	$373.50
Rate for Payer: BCBS MT CHIP	$373.50
Rate for Payer: BCBS MT Closed Plan Network	$394.25
Rate for Payer: BCBS MT HealthLink	$373.50
Rate for Payer: BCBS MT Medicare	$373.50
Rate for Payer: BCBS MT POS	$394.25
Rate for Payer: BCBS MT Traditional	$415.00
Rate for Payer: Cash Price	$373.50
Rate for Payer: Cigna Commercial	$394.25
Rate for Payer: Cigna Medicare	$373.50
Rate for Payer: Medicaid All Medicaid	$381.80
Rate for Payer: Medicare All Medicare	$290.50
Rate for Payer: Monida Allegiance	$394.25
Rate for Payer: Monida First Choice Health	$402.55
Rate for Payer: Monida Montana Health Co-op	$394.25
Rate for Payer: Monida PacificSource	$394.25

HLA DR GENOTYPING

Facility

$415.00

Service Code	CPT 81382
Hospital Charge Code	4088047
Hospital Revenue Code	302
Min. Negotiated Rate	$290.50
Max. Negotiated Rate	$415.00
Rate for Payer: Aetna Commercial	$394.25
Rate for Payer: Aetna Medicare	$373.50
Rate for Payer: BCBS MT CHIP	$373.50
Rate for Payer: BCBS MT Closed Plan Network	$394.25
Rate for Payer: BCBS MT HealthLink	$373.50
Rate for Payer: BCBS MT Medicare	$373.50
Rate for Payer: BCBS MT POS	$394.25
Rate for Payer: BCBS MT Traditional	$415.00
Rate for Payer: Cash Price	$373.50
Rate for Payer: Cigna Commercial	$394.25
Rate for Payer: Cigna Medicare	$373.50
Rate for Payer: Medicaid All Medicaid	$381.80
Rate for Payer: Medicare All Medicare	$290.50
Rate for Payer: Monida Allegiance	$394.25
Rate for Payer: Monida First Choice Health	$402.55
Rate for Payer: Monida Montana Health Co-op	$394.25
Rate for Payer: Monida PacificSource	$394.25

HOLTER 1-48HR APPLY/RECORD/DISCONNECT

Facility

$338.00

Service Code	CPT 93225
Hospital Charge Code	114006
Hospital Revenue Code	731
Min. Negotiated Rate	$236.60
Max. Negotiated Rate	$338.00
Rate for Payer: Aetna Commercial	$321.10
Rate for Payer: Aetna Medicare	$304.20
Rate for Payer: BCBS MT CHIP	$304.20
Rate for Payer: BCBS MT Closed Plan Network	$321.10
Rate for Payer: BCBS MT HealthLink	$304.20
Rate for Payer: BCBS MT Medicare	$304.20
Rate for Payer: BCBS MT POS	$321.10
Rate for Payer: BCBS MT Traditional	$338.00
Rate for Payer: Cash Price	$304.20
Rate for Payer: Cigna Commercial	$321.10
Rate for Payer: Cigna Medicare	$304.20
Rate for Payer: Medicaid All Medicaid	$310.96
Rate for Payer: Medicare All Medicare	$236.60
Rate for Payer: Monida Allegiance	$321.10
Rate for Payer: Monida First Choice Health	$327.86
Rate for Payer: Monida Montana Health Co-op	$321.10
Rate for Payer: Monida PacificSource	$321.10

HOLTER 1-48HR APPLY/RECORD/DISCONNECT

Facility

$338.00

Service Code	CPT 93225
Hospital Charge Code	114006
Hospital Revenue Code	731
Min. Negotiated Rate	$236.60
Max. Negotiated Rate	$338.00
Rate for Payer: Aetna Commercial	$321.10
Rate for Payer: Aetna Medicare	$304.20
Rate for Payer: BCBS MT CHIP	$304.20
Rate for Payer: BCBS MT Closed Plan Network	$321.10
Rate for Payer: BCBS MT HealthLink	$304.20
Rate for Payer: BCBS MT Medicare	$304.20
Rate for Payer: BCBS MT POS	$321.10
Rate for Payer: BCBS MT Traditional	$338.00
Rate for Payer: Cash Price	$304.20
Rate for Payer: Cigna Commercial	$321.10
Rate for Payer: Cigna Medicare	$304.20
Rate for Payer: Medicaid All Medicaid	$310.96
Rate for Payer: Medicare All Medicare	$236.60
Rate for Payer: Monida Allegiance	$321.10
Rate for Payer: Monida First Choice Health	$327.86
Rate for Payer: Monida Montana Health Co-op	$321.10
Rate for Payer: Monida PacificSource	$321.10

HOLTER 1-48HR SCAN ANALY W/REP- MEDICAID

Facility

$405.00

Service Code	CPT 93226
Hospital Charge Code	114007
Hospital Revenue Code	731
Min. Negotiated Rate	$283.50
Max. Negotiated Rate	$405.00
Rate for Payer: Aetna Commercial	$384.75
Rate for Payer: Aetna Medicare	$364.50
Rate for Payer: BCBS MT CHIP	$364.50
Rate for Payer: BCBS MT Closed Plan Network	$384.75
Rate for Payer: BCBS MT HealthLink	$364.50
Rate for Payer: BCBS MT Medicare	$364.50
Rate for Payer: BCBS MT POS	$384.75
Rate for Payer: BCBS MT Traditional	$405.00
Rate for Payer: Cash Price	$364.50
Rate for Payer: Cigna Commercial	$384.75
Rate for Payer: Cigna Medicare	$364.50
Rate for Payer: Medicaid All Medicaid	$372.60
Rate for Payer: Medicare All Medicare	$283.50
Rate for Payer: Monida Allegiance	$384.75
Rate for Payer: Monida First Choice Health	$392.85
Rate for Payer: Monida Montana Health Co-op	$384.75
Rate for Payer: Monida PacificSource	$384.75

HOLTER 1-48HR SCAN ANALY W/REP- MEDICAID

Facility

$405.00

Service Code	CPT 93226
Hospital Charge Code	114007
Hospital Revenue Code	731
Min. Negotiated Rate	$283.50
Max. Negotiated Rate	$405.00
Rate for Payer: Aetna Commercial	$384.75
Rate for Payer: Aetna Medicare	$364.50
Rate for Payer: BCBS MT CHIP	$364.50
Rate for Payer: BCBS MT Closed Plan Network	$384.75
Rate for Payer: BCBS MT HealthLink	$364.50
Rate for Payer: BCBS MT Medicare	$364.50
Rate for Payer: BCBS MT POS	$384.75
Rate for Payer: BCBS MT Traditional	$405.00
Rate for Payer: Cash Price	$364.50
Rate for Payer: Cigna Commercial	$384.75
Rate for Payer: Cigna Medicare	$364.50
Rate for Payer: Medicaid All Medicaid	$372.60
Rate for Payer: Medicare All Medicare	$283.50
Rate for Payer: Monida Allegiance	$384.75
Rate for Payer: Monida First Choice Health	$392.85
Rate for Payer: Monida Montana Health Co-op	$384.75
Rate for Payer: Monida PacificSource	$384.75

HOLTER 49HR-7DAY APPLY/RECORD/DISCONNECT

Facility

$251.00

Service Code	CPT 93242
Hospital Charge Code	114010
Hospital Revenue Code	731
Min. Negotiated Rate	$175.70
Max. Negotiated Rate	$251.00
Rate for Payer: Aetna Commercial	$238.45
Rate for Payer: Aetna Medicare	$225.90
Rate for Payer: BCBS MT CHIP	$225.90
Rate for Payer: BCBS MT Closed Plan Network	$238.45
Rate for Payer: BCBS MT HealthLink	$225.90
Rate for Payer: BCBS MT Medicare	$225.90
Rate for Payer: BCBS MT POS	$238.45
Rate for Payer: BCBS MT Traditional	$251.00
Rate for Payer: Cash Price	$225.90
Rate for Payer: Cigna Commercial	$238.45
Rate for Payer: Cigna Medicare	$225.90
Rate for Payer: Medicaid All Medicaid	$230.92
Rate for Payer: Medicare All Medicare	$175.70
Rate for Payer: Monida Allegiance	$238.45
Rate for Payer: Monida First Choice Health	$243.47
Rate for Payer: Monida Montana Health Co-op	$238.45
Rate for Payer: Monida PacificSource	$238.45

HOLTER 49HR-7DAY APPLY/RECORD/DISCONNECT

Facility

$251.00

Service Code	CPT 93242
Hospital Charge Code	114010
Hospital Revenue Code	731
Min. Negotiated Rate	$175.70
Max. Negotiated Rate	$251.00
Rate for Payer: Aetna Commercial	$238.45
Rate for Payer: Aetna Medicare	$225.90
Rate for Payer: BCBS MT CHIP	$225.90
Rate for Payer: BCBS MT Closed Plan Network	$238.45
Rate for Payer: BCBS MT HealthLink	$225.90
Rate for Payer: BCBS MT Medicare	$225.90
Rate for Payer: BCBS MT POS	$238.45
Rate for Payer: BCBS MT Traditional	$251.00
Rate for Payer: Cash Price	$225.90
Rate for Payer: Cigna Commercial	$238.45
Rate for Payer: Cigna Medicare	$225.90
Rate for Payer: Medicaid All Medicaid	$230.92
Rate for Payer: Medicare All Medicare	$175.70
Rate for Payer: Monida Allegiance	$238.45
Rate for Payer: Monida First Choice Health	$243.47
Rate for Payer: Monida Montana Health Co-op	$238.45
Rate for Payer: Monida PacificSource	$238.45

HOLTER 49HR-7DAY SCAN ANALY W/REP -MEDIC

Facility

$251.00

Service Code	CPT 93243
Hospital Charge Code	114011
Hospital Revenue Code	731
Min. Negotiated Rate	$175.70
Max. Negotiated Rate	$251.00
Rate for Payer: Aetna Commercial	$238.45
Rate for Payer: Aetna Medicare	$225.90
Rate for Payer: BCBS MT CHIP	$225.90
Rate for Payer: BCBS MT Closed Plan Network	$238.45
Rate for Payer: BCBS MT HealthLink	$225.90
Rate for Payer: BCBS MT Medicare	$225.90
Rate for Payer: BCBS MT POS	$238.45
Rate for Payer: BCBS MT Traditional	$251.00
Rate for Payer: Cash Price	$225.90
Rate for Payer: Cigna Commercial	$238.45
Rate for Payer: Cigna Medicare	$225.90
Rate for Payer: Medicaid All Medicaid	$230.92
Rate for Payer: Medicare All Medicare	$175.70
Rate for Payer: Monida Allegiance	$238.45
Rate for Payer: Monida First Choice Health	$243.47
Rate for Payer: Monida Montana Health Co-op	$238.45
Rate for Payer: Monida PacificSource	$238.45

HOLTER 49HR-7DAY SCAN ANALY W/REP -MEDIC

Facility

$251.00

Service Code	CPT 93243
Hospital Charge Code	114011
Hospital Revenue Code	731
Min. Negotiated Rate	$175.70
Max. Negotiated Rate	$251.00
Rate for Payer: Aetna Commercial	$238.45
Rate for Payer: Aetna Medicare	$225.90
Rate for Payer: BCBS MT CHIP	$225.90
Rate for Payer: BCBS MT Closed Plan Network	$238.45
Rate for Payer: BCBS MT HealthLink	$225.90
Rate for Payer: BCBS MT Medicare	$225.90
Rate for Payer: BCBS MT POS	$238.45
Rate for Payer: BCBS MT Traditional	$251.00
Rate for Payer: Cash Price	$225.90
Rate for Payer: Cigna Commercial	$238.45
Rate for Payer: Cigna Medicare	$225.90
Rate for Payer: Medicaid All Medicaid	$230.92
Rate for Payer: Medicare All Medicare	$175.70
Rate for Payer: Monida Allegiance	$238.45
Rate for Payer: Monida First Choice Health	$243.47
Rate for Payer: Monida Montana Health Co-op	$238.45
Rate for Payer: Monida PacificSource	$238.45

HOLTER 49HR-7DAYS RECORD/ANALY/INTERPRET

Facility

$473.00

Service Code	CPT 93241
Hospital Charge Code	114009
Hospital Revenue Code	731
Min. Negotiated Rate	$331.10
Max. Negotiated Rate	$473.00
Rate for Payer: Aetna Commercial	$449.35
Rate for Payer: Aetna Medicare	$425.70
Rate for Payer: BCBS MT CHIP	$425.70
Rate for Payer: BCBS MT Closed Plan Network	$449.35
Rate for Payer: BCBS MT HealthLink	$425.70
Rate for Payer: BCBS MT Medicare	$425.70
Rate for Payer: BCBS MT POS	$449.35
Rate for Payer: BCBS MT Traditional	$473.00
Rate for Payer: Cash Price	$425.70
Rate for Payer: Cigna Commercial	$449.35
Rate for Payer: Cigna Medicare	$425.70
Rate for Payer: Medicaid All Medicaid	$435.16
Rate for Payer: Medicare All Medicare	$331.10
Rate for Payer: Monida Allegiance	$449.35
Rate for Payer: Monida First Choice Health	$458.81
Rate for Payer: Monida Montana Health Co-op	$449.35
Rate for Payer: Monida PacificSource	$449.35

HOLTER 49HR-7DAYS RECORD/ANALY/INTERPRET

Facility

$473.00

Service Code	CPT 93241
Hospital Charge Code	114009
Hospital Revenue Code	731
Min. Negotiated Rate	$331.10
Max. Negotiated Rate	$473.00
Rate for Payer: Aetna Commercial	$449.35
Rate for Payer: Aetna Medicare	$425.70
Rate for Payer: BCBS MT CHIP	$425.70
Rate for Payer: BCBS MT Closed Plan Network	$449.35
Rate for Payer: BCBS MT HealthLink	$425.70
Rate for Payer: BCBS MT Medicare	$425.70
Rate for Payer: BCBS MT POS	$449.35
Rate for Payer: BCBS MT Traditional	$473.00
Rate for Payer: Cash Price	$425.70
Rate for Payer: Cigna Commercial	$449.35
Rate for Payer: Cigna Medicare	$425.70
Rate for Payer: Medicaid All Medicaid	$435.16
Rate for Payer: Medicare All Medicare	$331.10
Rate for Payer: Monida Allegiance	$449.35
Rate for Payer: Monida First Choice Health	$458.81
Rate for Payer: Monida Montana Health Co-op	$449.35
Rate for Payer: Monida PacificSource	$449.35

HOLTER 8-15 DAYS APPLY/RECORD/DISCONNECT

Facility

$251.00

Service Code	CPT 93246
Hospital Charge Code	114005
Hospital Revenue Code	731
Min. Negotiated Rate	$175.70
Max. Negotiated Rate	$251.00
Rate for Payer: Aetna Commercial	$238.45
Rate for Payer: Aetna Medicare	$225.90
Rate for Payer: BCBS MT CHIP	$225.90
Rate for Payer: BCBS MT Closed Plan Network	$238.45
Rate for Payer: BCBS MT HealthLink	$225.90
Rate for Payer: BCBS MT Medicare	$225.90
Rate for Payer: BCBS MT POS	$238.45
Rate for Payer: BCBS MT Traditional	$251.00
Rate for Payer: Cash Price	$225.90
Rate for Payer: Cigna Commercial	$238.45
Rate for Payer: Cigna Medicare	$225.90
Rate for Payer: Medicaid All Medicaid	$230.92
Rate for Payer: Medicare All Medicare	$175.70
Rate for Payer: Monida Allegiance	$238.45
Rate for Payer: Monida First Choice Health	$243.47
Rate for Payer: Monida Montana Health Co-op	$238.45
Rate for Payer: Monida PacificSource	$238.45

Know your out-of-pocket cost for care.

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