Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

SS-B/LA ANTIBODIES, IGG (012690)

Facility

$114.00

Service Code	HCPCS 86235
Hospital Charge Code	4000067
Hospital Revenue Code	300
Min. Negotiated Rate	$79.80
Max. Negotiated Rate	$114.00
Rate for Payer: Aetna Commercial	$108.30
Rate for Payer: Aetna Medicare	$102.60
Rate for Payer: BCBS MT CHIP	$102.60
Rate for Payer: BCBS MT Closed Plan Network	$108.30
Rate for Payer: BCBS MT HealthLink	$102.60
Rate for Payer: BCBS MT Medicare	$102.60
Rate for Payer: BCBS MT POS	$108.30
Rate for Payer: BCBS MT Traditional	$114.00
Rate for Payer: Cash Price	$102.60
Rate for Payer: Cigna Commercial	$108.30
Rate for Payer: Cigna Medicare	$102.60
Rate for Payer: Medicaid All Medicaid	$104.88
Rate for Payer: Medicare All Medicare	$79.80
Rate for Payer: Monida Allegiance	$108.30
Rate for Payer: Monida First Choice Health	$110.58
Rate for Payer: Monida Montana Health Co-op	$108.30
Rate for Payer: Monida PacificSource	$108.30

ST ASSESS APHASIA W/REPORT

Facility

$293.00

Service Code	HCPCS 96105 GN
Hospital Charge Code	6396105
Hospital Revenue Code	440
Min. Negotiated Rate	$205.10
Max. Negotiated Rate	$293.00
Rate for Payer: Aetna Commercial	$278.35
Rate for Payer: Aetna Medicare	$263.70
Rate for Payer: BCBS MT CHIP	$263.70
Rate for Payer: BCBS MT Closed Plan Network	$278.35
Rate for Payer: BCBS MT HealthLink	$263.70
Rate for Payer: BCBS MT Medicare	$263.70
Rate for Payer: BCBS MT POS	$278.35
Rate for Payer: BCBS MT Traditional	$293.00
Rate for Payer: Cash Price	$263.70
Rate for Payer: Cigna Commercial	$278.35
Rate for Payer: Cigna Medicare	$263.70
Rate for Payer: Medicaid All Medicaid	$269.56
Rate for Payer: Medicare All Medicare	$205.10
Rate for Payer: Monida Allegiance	$278.35
Rate for Payer: Monida First Choice Health	$284.21
Rate for Payer: Monida Montana Health Co-op	$278.35
Rate for Payer: Monida PacificSource	$278.35

ST ASSESS APHASIA W/REPORT

Facility

$293.00

Service Code	HCPCS 96105 GN
Hospital Charge Code	6396105
Hospital Revenue Code	440
Min. Negotiated Rate	$205.10
Max. Negotiated Rate	$293.00
Rate for Payer: Aetna Commercial	$278.35
Rate for Payer: Aetna Medicare	$263.70
Rate for Payer: BCBS MT CHIP	$263.70
Rate for Payer: BCBS MT Closed Plan Network	$278.35
Rate for Payer: BCBS MT HealthLink	$263.70
Rate for Payer: BCBS MT Medicare	$263.70
Rate for Payer: BCBS MT POS	$278.35
Rate for Payer: BCBS MT Traditional	$293.00
Rate for Payer: Cash Price	$263.70
Rate for Payer: Cigna Commercial	$278.35
Rate for Payer: Cigna Medicare	$263.70
Rate for Payer: Medicaid All Medicaid	$269.56
Rate for Payer: Medicare All Medicare	$205.10
Rate for Payer: Monida Allegiance	$278.35
Rate for Payer: Monida First Choice Health	$284.21
Rate for Payer: Monida Montana Health Co-op	$278.35
Rate for Payer: Monida PacificSource	$278.35

ST BEHAVIORAL AND QUALITATIVE ANALYSIS

Facility

$266.00

Service Code	HCPCS 92524 GN
Hospital Charge Code	6392524
Hospital Revenue Code	440
Min. Negotiated Rate	$186.20
Max. Negotiated Rate	$266.00
Rate for Payer: Aetna Commercial	$252.70
Rate for Payer: Aetna Medicare	$239.40
Rate for Payer: BCBS MT CHIP	$239.40
Rate for Payer: BCBS MT Closed Plan Network	$252.70
Rate for Payer: BCBS MT HealthLink	$239.40
Rate for Payer: BCBS MT Medicare	$239.40
Rate for Payer: BCBS MT POS	$252.70
Rate for Payer: BCBS MT Traditional	$266.00
Rate for Payer: Cash Price	$239.40
Rate for Payer: Cigna Commercial	$252.70
Rate for Payer: Cigna Medicare	$239.40
Rate for Payer: Medicaid All Medicaid	$244.72
Rate for Payer: Medicare All Medicare	$186.20
Rate for Payer: Monida Allegiance	$252.70
Rate for Payer: Monida First Choice Health	$258.02
Rate for Payer: Monida Montana Health Co-op	$252.70
Rate for Payer: Monida PacificSource	$252.70

ST BEHAVIORAL AND QUALITATIVE ANALYSIS

Facility

$266.00

Service Code	HCPCS 92524 GN
Hospital Charge Code	6392524
Hospital Revenue Code	440
Min. Negotiated Rate	$186.20
Max. Negotiated Rate	$266.00
Rate for Payer: Aetna Commercial	$252.70
Rate for Payer: Aetna Medicare	$239.40
Rate for Payer: BCBS MT CHIP	$239.40
Rate for Payer: BCBS MT Closed Plan Network	$252.70
Rate for Payer: BCBS MT HealthLink	$239.40
Rate for Payer: BCBS MT Medicare	$239.40
Rate for Payer: BCBS MT POS	$252.70
Rate for Payer: BCBS MT Traditional	$266.00
Rate for Payer: Cash Price	$239.40
Rate for Payer: Cigna Commercial	$252.70
Rate for Payer: Cigna Medicare	$239.40
Rate for Payer: Medicaid All Medicaid	$244.72
Rate for Payer: Medicare All Medicare	$186.20
Rate for Payer: Monida Allegiance	$252.70
Rate for Payer: Monida First Choice Health	$258.02
Rate for Payer: Monida Montana Health Co-op	$252.70
Rate for Payer: Monida PacificSource	$252.70

ST DEVELOPMENTAL TESTING LIMITED

Facility

$32.00

Service Code	HCPCS 96110 GN
Hospital Charge Code	6396110
Hospital Revenue Code	440
Min. Negotiated Rate	$22.40
Max. Negotiated Rate	$32.00
Rate for Payer: Aetna Commercial	$30.40
Rate for Payer: Aetna Medicare	$28.80
Rate for Payer: BCBS MT CHIP	$28.80
Rate for Payer: BCBS MT Closed Plan Network	$30.40
Rate for Payer: BCBS MT HealthLink	$28.80
Rate for Payer: BCBS MT Medicare	$28.80
Rate for Payer: BCBS MT POS	$30.40
Rate for Payer: BCBS MT Traditional	$32.00
Rate for Payer: Cash Price	$28.80
Rate for Payer: Cigna Commercial	$30.40
Rate for Payer: Cigna Medicare	$28.80
Rate for Payer: Medicaid All Medicaid	$29.44
Rate for Payer: Medicare All Medicare	$22.40
Rate for Payer: Monida Allegiance	$30.40
Rate for Payer: Monida First Choice Health	$31.04
Rate for Payer: Monida Montana Health Co-op	$30.40
Rate for Payer: Monida PacificSource	$30.40

ST DEVELOPMENTAL TESTING LIMITED

Facility

$32.00

Service Code	HCPCS 96110 GN
Hospital Charge Code	6396110
Hospital Revenue Code	440
Min. Negotiated Rate	$22.40
Max. Negotiated Rate	$32.00
Rate for Payer: Aetna Commercial	$30.40
Rate for Payer: Aetna Medicare	$28.80
Rate for Payer: BCBS MT CHIP	$28.80
Rate for Payer: BCBS MT Closed Plan Network	$30.40
Rate for Payer: BCBS MT HealthLink	$28.80
Rate for Payer: BCBS MT Medicare	$28.80
Rate for Payer: BCBS MT POS	$30.40
Rate for Payer: BCBS MT Traditional	$32.00
Rate for Payer: Cash Price	$28.80
Rate for Payer: Cigna Commercial	$30.40
Rate for Payer: Cigna Medicare	$28.80
Rate for Payer: Medicaid All Medicaid	$29.44
Rate for Payer: Medicare All Medicare	$22.40
Rate for Payer: Monida Allegiance	$30.40
Rate for Payer: Monida First Choice Health	$31.04
Rate for Payer: Monida Montana Health Co-op	$30.40
Rate for Payer: Monida PacificSource	$30.40

STERILE TOWEL DRAPE (FENESTRAT

Facility

$20.00

Hospital Charge Code	80030489
Hospital Revenue Code	270
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

STERILE TOWEL DRAPE (FENESTRAT

Facility

$20.00

Hospital Charge Code	80030489
Hospital Revenue Code	270
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

STERILE TOWEL DRAPE (PLAIN)

Facility

$4.00

Hospital Charge Code	80030488
Hospital Revenue Code	270
Min. Negotiated Rate	$2.80
Max. Negotiated Rate	$4.00
Rate for Payer: Aetna Commercial	$3.80
Rate for Payer: Aetna Medicare	$3.60
Rate for Payer: BCBS MT CHIP	$3.60
Rate for Payer: BCBS MT Closed Plan Network	$3.80
Rate for Payer: BCBS MT HealthLink	$3.60
Rate for Payer: BCBS MT Medicare	$3.60
Rate for Payer: BCBS MT POS	$3.80
Rate for Payer: BCBS MT Traditional	$4.00
Rate for Payer: Cash Price	$3.60
Rate for Payer: Cigna Commercial	$3.80
Rate for Payer: Cigna Medicare	$3.60
Rate for Payer: Medicaid All Medicaid	$3.68
Rate for Payer: Medicare All Medicare	$2.80
Rate for Payer: Monida Allegiance	$3.80
Rate for Payer: Monida First Choice Health	$3.88
Rate for Payer: Monida Montana Health Co-op	$3.80
Rate for Payer: Monida PacificSource	$3.80

STERILE TOWEL DRAPE (PLAIN)

Facility

$4.00

Hospital Charge Code	80030488
Hospital Revenue Code	270
Min. Negotiated Rate	$2.80
Max. Negotiated Rate	$4.00
Rate for Payer: Aetna Commercial	$3.80
Rate for Payer: Aetna Medicare	$3.60
Rate for Payer: BCBS MT CHIP	$3.60
Rate for Payer: BCBS MT Closed Plan Network	$3.80
Rate for Payer: BCBS MT HealthLink	$3.60
Rate for Payer: BCBS MT Medicare	$3.60
Rate for Payer: BCBS MT POS	$3.80
Rate for Payer: BCBS MT Traditional	$4.00
Rate for Payer: Cash Price	$3.60
Rate for Payer: Cigna Commercial	$3.80
Rate for Payer: Cigna Medicare	$3.60
Rate for Payer: Medicaid All Medicaid	$3.68
Rate for Payer: Medicare All Medicare	$2.80
Rate for Payer: Monida Allegiance	$3.80
Rate for Payer: Monida First Choice Health	$3.88
Rate for Payer: Monida Montana Health Co-op	$3.80
Rate for Payer: Monida PacificSource	$3.80

STERISTRIPS 1/4X4

Facility

$21.00

Hospital Charge Code	80030414
Hospital Revenue Code	270
Min. Negotiated Rate	$14.70
Max. Negotiated Rate	$21.00
Rate for Payer: Aetna Commercial	$19.95
Rate for Payer: Aetna Medicare	$18.90
Rate for Payer: BCBS MT CHIP	$18.90
Rate for Payer: BCBS MT Closed Plan Network	$19.95
Rate for Payer: BCBS MT HealthLink	$18.90
Rate for Payer: BCBS MT Medicare	$18.90
Rate for Payer: BCBS MT POS	$19.95
Rate for Payer: BCBS MT Traditional	$21.00
Rate for Payer: Cash Price	$18.90
Rate for Payer: Cigna Commercial	$19.95
Rate for Payer: Cigna Medicare	$18.90
Rate for Payer: Medicaid All Medicaid	$19.32
Rate for Payer: Medicare All Medicare	$14.70
Rate for Payer: Monida Allegiance	$19.95
Rate for Payer: Monida First Choice Health	$20.37
Rate for Payer: Monida Montana Health Co-op	$19.95
Rate for Payer: Monida PacificSource	$19.95

STERISTRIPS 1/4X4

Facility

$21.00

Hospital Charge Code	80030414
Hospital Revenue Code	270
Min. Negotiated Rate	$14.70
Max. Negotiated Rate	$21.00
Rate for Payer: Aetna Commercial	$19.95
Rate for Payer: Aetna Medicare	$18.90
Rate for Payer: BCBS MT CHIP	$18.90
Rate for Payer: BCBS MT Closed Plan Network	$19.95
Rate for Payer: BCBS MT HealthLink	$18.90
Rate for Payer: BCBS MT Medicare	$18.90
Rate for Payer: BCBS MT POS	$19.95
Rate for Payer: BCBS MT Traditional	$21.00
Rate for Payer: Cash Price	$18.90
Rate for Payer: Cigna Commercial	$19.95
Rate for Payer: Cigna Medicare	$18.90
Rate for Payer: Medicaid All Medicaid	$19.32
Rate for Payer: Medicare All Medicare	$14.70
Rate for Payer: Monida Allegiance	$19.95
Rate for Payer: Monida First Choice Health	$20.37
Rate for Payer: Monida Montana Health Co-op	$19.95
Rate for Payer: Monida PacificSource	$19.95

ST EVAL OF ORAL&PHARYNGEAL SWALLOWING F

Facility

$677.00

Service Code	HCPCS 92610 GN
Hospital Charge Code	6392610
Hospital Revenue Code	440
Min. Negotiated Rate	$473.90
Max. Negotiated Rate	$677.00
Rate for Payer: Aetna Commercial	$643.15
Rate for Payer: Aetna Medicare	$609.30
Rate for Payer: BCBS MT CHIP	$609.30
Rate for Payer: BCBS MT Closed Plan Network	$643.15
Rate for Payer: BCBS MT HealthLink	$609.30
Rate for Payer: BCBS MT Medicare	$609.30
Rate for Payer: BCBS MT POS	$643.15
Rate for Payer: BCBS MT Traditional	$677.00
Rate for Payer: Cash Price	$609.30
Rate for Payer: Cigna Commercial	$643.15
Rate for Payer: Cigna Medicare	$609.30
Rate for Payer: Medicaid All Medicaid	$622.84
Rate for Payer: Medicare All Medicare	$473.90
Rate for Payer: Monida Allegiance	$643.15
Rate for Payer: Monida First Choice Health	$656.69
Rate for Payer: Monida Montana Health Co-op	$643.15
Rate for Payer: Monida PacificSource	$643.15

ST EVAL OF ORAL&PHARYNGEAL SWALLOWING F

Facility

$677.00

Service Code	HCPCS 92610 GN
Hospital Charge Code	6392610
Hospital Revenue Code	440
Min. Negotiated Rate	$473.90
Max. Negotiated Rate	$677.00
Rate for Payer: Aetna Commercial	$643.15
Rate for Payer: Aetna Medicare	$609.30
Rate for Payer: BCBS MT CHIP	$609.30
Rate for Payer: BCBS MT Closed Plan Network	$643.15
Rate for Payer: BCBS MT HealthLink	$609.30
Rate for Payer: BCBS MT Medicare	$609.30
Rate for Payer: BCBS MT POS	$643.15
Rate for Payer: BCBS MT Traditional	$677.00
Rate for Payer: Cash Price	$609.30
Rate for Payer: Cigna Commercial	$643.15
Rate for Payer: Cigna Medicare	$609.30
Rate for Payer: Medicaid All Medicaid	$622.84
Rate for Payer: Medicare All Medicare	$473.90
Rate for Payer: Monida Allegiance	$643.15
Rate for Payer: Monida First Choice Health	$656.69
Rate for Payer: Monida Montana Health Co-op	$643.15
Rate for Payer: Monida PacificSource	$643.15

ST EVAL SPEECH FLUENCY(STUTTERING CLUTT

Facility

$332.00

Service Code	HCPCS 92521 GN
Hospital Charge Code	6392521
Hospital Revenue Code	440
Min. Negotiated Rate	$232.40
Max. Negotiated Rate	$332.00
Rate for Payer: Aetna Commercial	$315.40
Rate for Payer: Aetna Medicare	$298.80
Rate for Payer: BCBS MT CHIP	$298.80
Rate for Payer: BCBS MT Closed Plan Network	$315.40
Rate for Payer: BCBS MT HealthLink	$298.80
Rate for Payer: BCBS MT Medicare	$298.80
Rate for Payer: BCBS MT POS	$315.40
Rate for Payer: BCBS MT Traditional	$332.00
Rate for Payer: Cash Price	$298.80
Rate for Payer: Cigna Commercial	$315.40
Rate for Payer: Cigna Medicare	$298.80
Rate for Payer: Medicaid All Medicaid	$305.44
Rate for Payer: Medicare All Medicare	$232.40
Rate for Payer: Monida Allegiance	$315.40
Rate for Payer: Monida First Choice Health	$322.04
Rate for Payer: Monida Montana Health Co-op	$315.40
Rate for Payer: Monida PacificSource	$315.40

ST EVAL SPEECH FLUENCY(STUTTERING CLUTT

Facility

$332.00

Service Code	HCPCS 92521 GN
Hospital Charge Code	6392521
Hospital Revenue Code	440
Min. Negotiated Rate	$232.40
Max. Negotiated Rate	$332.00
Rate for Payer: Aetna Commercial	$315.40
Rate for Payer: Aetna Medicare	$298.80
Rate for Payer: BCBS MT CHIP	$298.80
Rate for Payer: BCBS MT Closed Plan Network	$315.40
Rate for Payer: BCBS MT HealthLink	$298.80
Rate for Payer: BCBS MT Medicare	$298.80
Rate for Payer: BCBS MT POS	$315.40
Rate for Payer: BCBS MT Traditional	$332.00
Rate for Payer: Cash Price	$298.80
Rate for Payer: Cigna Commercial	$315.40
Rate for Payer: Cigna Medicare	$298.80
Rate for Payer: Medicaid All Medicaid	$305.44
Rate for Payer: Medicare All Medicare	$232.40
Rate for Payer: Monida Allegiance	$315.40
Rate for Payer: Monida First Choice Health	$322.04
Rate for Payer: Monida Montana Health Co-op	$315.40
Rate for Payer: Monida PacificSource	$315.40

ST EVAL SPEECH SOUND PROD LANGUAGE

Facility

$332.00

Service Code	HCPCS 92523 GN
Hospital Charge Code	6392523
Hospital Revenue Code	440
Min. Negotiated Rate	$232.40
Max. Negotiated Rate	$332.00
Rate for Payer: Aetna Commercial	$315.40
Rate for Payer: Aetna Medicare	$298.80
Rate for Payer: BCBS MT CHIP	$298.80
Rate for Payer: BCBS MT Closed Plan Network	$315.40
Rate for Payer: BCBS MT HealthLink	$298.80
Rate for Payer: BCBS MT Medicare	$298.80
Rate for Payer: BCBS MT POS	$315.40
Rate for Payer: BCBS MT Traditional	$332.00
Rate for Payer: Cash Price	$298.80
Rate for Payer: Cigna Commercial	$315.40
Rate for Payer: Cigna Medicare	$298.80
Rate for Payer: Medicaid All Medicaid	$305.44
Rate for Payer: Medicare All Medicare	$232.40
Rate for Payer: Monida Allegiance	$315.40
Rate for Payer: Monida First Choice Health	$322.04
Rate for Payer: Monida Montana Health Co-op	$315.40
Rate for Payer: Monida PacificSource	$315.40

ST EVAL SPEECH SOUND PROD LANGUAGE

Facility

$332.00

Service Code	HCPCS 92523 GN
Hospital Charge Code	6392523
Hospital Revenue Code	440
Min. Negotiated Rate	$232.40
Max. Negotiated Rate	$332.00
Rate for Payer: Aetna Commercial	$315.40
Rate for Payer: Aetna Medicare	$298.80
Rate for Payer: BCBS MT CHIP	$298.80
Rate for Payer: BCBS MT Closed Plan Network	$315.40
Rate for Payer: BCBS MT HealthLink	$298.80
Rate for Payer: BCBS MT Medicare	$298.80
Rate for Payer: BCBS MT POS	$315.40
Rate for Payer: BCBS MT Traditional	$332.00
Rate for Payer: Cash Price	$298.80
Rate for Payer: Cigna Commercial	$315.40
Rate for Payer: Cigna Medicare	$298.80
Rate for Payer: Medicaid All Medicaid	$305.44
Rate for Payer: Medicare All Medicare	$232.40
Rate for Payer: Monida Allegiance	$315.40
Rate for Payer: Monida First Choice Health	$322.04
Rate for Payer: Monida Montana Health Co-op	$315.40
Rate for Payer: Monida PacificSource	$315.40

ST EVAL SPEECH SOUND PRODUCTION

Facility

$332.00

Service Code	HCPCS 92522 GN
Hospital Charge Code	6392522
Hospital Revenue Code	440
Min. Negotiated Rate	$232.40
Max. Negotiated Rate	$332.00
Rate for Payer: Aetna Commercial	$315.40
Rate for Payer: Aetna Medicare	$298.80
Rate for Payer: BCBS MT CHIP	$298.80
Rate for Payer: BCBS MT Closed Plan Network	$315.40
Rate for Payer: BCBS MT HealthLink	$298.80
Rate for Payer: BCBS MT Medicare	$298.80
Rate for Payer: BCBS MT POS	$315.40
Rate for Payer: BCBS MT Traditional	$332.00
Rate for Payer: Cash Price	$298.80
Rate for Payer: Cigna Commercial	$315.40
Rate for Payer: Cigna Medicare	$298.80
Rate for Payer: Medicaid All Medicaid	$305.44
Rate for Payer: Medicare All Medicare	$232.40
Rate for Payer: Monida Allegiance	$315.40
Rate for Payer: Monida First Choice Health	$322.04
Rate for Payer: Monida Montana Health Co-op	$315.40
Rate for Payer: Monida PacificSource	$315.40

ST EVAL SPEECH SOUND PRODUCTION

Facility

$332.00

Service Code	HCPCS 92522 GN
Hospital Charge Code	6392522
Hospital Revenue Code	440
Min. Negotiated Rate	$232.40
Max. Negotiated Rate	$332.00
Rate for Payer: Aetna Commercial	$315.40
Rate for Payer: Aetna Medicare	$298.80
Rate for Payer: BCBS MT CHIP	$298.80
Rate for Payer: BCBS MT Closed Plan Network	$315.40
Rate for Payer: BCBS MT HealthLink	$298.80
Rate for Payer: BCBS MT Medicare	$298.80
Rate for Payer: BCBS MT POS	$315.40
Rate for Payer: BCBS MT Traditional	$332.00
Rate for Payer: Cash Price	$298.80
Rate for Payer: Cigna Commercial	$315.40
Rate for Payer: Cigna Medicare	$298.80
Rate for Payer: Medicaid All Medicaid	$305.44
Rate for Payer: Medicare All Medicare	$232.40
Rate for Payer: Monida Allegiance	$315.40
Rate for Payer: Monida First Choice Health	$322.04
Rate for Payer: Monida Montana Health Co-op	$315.40
Rate for Payer: Monida PacificSource	$315.40

ST EVAL VOICE PROSTH/AUG COMM

Facility

$363.00

Service Code	HCPCS 92597 GN
Hospital Charge Code	6392597
Hospital Revenue Code	440
Min. Negotiated Rate	$254.10
Max. Negotiated Rate	$363.00
Rate for Payer: Aetna Commercial	$344.85
Rate for Payer: Aetna Medicare	$326.70
Rate for Payer: BCBS MT CHIP	$326.70
Rate for Payer: BCBS MT Closed Plan Network	$344.85
Rate for Payer: BCBS MT HealthLink	$326.70
Rate for Payer: BCBS MT Medicare	$326.70
Rate for Payer: BCBS MT POS	$344.85
Rate for Payer: BCBS MT Traditional	$363.00
Rate for Payer: Cash Price	$326.70
Rate for Payer: Cigna Commercial	$344.85
Rate for Payer: Cigna Medicare	$326.70
Rate for Payer: Medicaid All Medicaid	$333.96
Rate for Payer: Medicare All Medicare	$254.10
Rate for Payer: Monida Allegiance	$344.85
Rate for Payer: Monida First Choice Health	$352.11
Rate for Payer: Monida Montana Health Co-op	$344.85
Rate for Payer: Monida PacificSource	$344.85

ST EVAL VOICE PROSTH/AUG COMM

Facility

$363.00

Service Code	HCPCS 92597 GN
Hospital Charge Code	6392597
Hospital Revenue Code	440
Min. Negotiated Rate	$254.10
Max. Negotiated Rate	$363.00
Rate for Payer: Aetna Commercial	$344.85
Rate for Payer: Aetna Medicare	$326.70
Rate for Payer: BCBS MT CHIP	$326.70
Rate for Payer: BCBS MT Closed Plan Network	$344.85
Rate for Payer: BCBS MT HealthLink	$326.70
Rate for Payer: BCBS MT Medicare	$326.70
Rate for Payer: BCBS MT POS	$344.85
Rate for Payer: BCBS MT Traditional	$363.00
Rate for Payer: Cash Price	$326.70
Rate for Payer: Cigna Commercial	$344.85
Rate for Payer: Cigna Medicare	$326.70
Rate for Payer: Medicaid All Medicaid	$333.96
Rate for Payer: Medicare All Medicare	$254.10
Rate for Payer: Monida Allegiance	$344.85
Rate for Payer: Monida First Choice Health	$352.11
Rate for Payer: Monida Montana Health Co-op	$344.85
Rate for Payer: Monida PacificSource	$344.85

ST GROUP THERAPEUTIC PROC

Facility

$90.00

Service Code	HCPCS 97150 GN
Hospital Charge Code	6397150
Hospital Revenue Code	440
Min. Negotiated Rate	$63.00
Max. Negotiated Rate	$90.00
Rate for Payer: Aetna Commercial	$85.50
Rate for Payer: Aetna Medicare	$81.00
Rate for Payer: BCBS MT CHIP	$81.00
Rate for Payer: BCBS MT Closed Plan Network	$85.50
Rate for Payer: BCBS MT HealthLink	$81.00
Rate for Payer: BCBS MT Medicare	$81.00
Rate for Payer: BCBS MT POS	$85.50
Rate for Payer: BCBS MT Traditional	$90.00
Rate for Payer: Cash Price	$81.00
Rate for Payer: Cigna Commercial	$85.50
Rate for Payer: Cigna Medicare	$81.00
Rate for Payer: Medicaid All Medicaid	$82.80
Rate for Payer: Medicare All Medicare	$63.00
Rate for Payer: Monida Allegiance	$85.50
Rate for Payer: Monida First Choice Health	$87.30
Rate for Payer: Monida Montana Health Co-op	$85.50
Rate for Payer: Monida PacificSource	$85.50

ST GROUP THERAPEUTIC PROC

Facility

$90.00

Service Code	HCPCS 97150 GN
Hospital Charge Code	6397150
Hospital Revenue Code	440
Min. Negotiated Rate	$63.00
Max. Negotiated Rate	$90.00
Rate for Payer: Aetna Commercial	$85.50
Rate for Payer: Aetna Medicare	$81.00
Rate for Payer: BCBS MT CHIP	$81.00
Rate for Payer: BCBS MT Closed Plan Network	$85.50
Rate for Payer: BCBS MT HealthLink	$81.00
Rate for Payer: BCBS MT Medicare	$81.00
Rate for Payer: BCBS MT POS	$85.50
Rate for Payer: BCBS MT Traditional	$90.00
Rate for Payer: Cash Price	$81.00
Rate for Payer: Cigna Commercial	$85.50
Rate for Payer: Cigna Medicare	$81.00
Rate for Payer: Medicaid All Medicaid	$82.80
Rate for Payer: Medicare All Medicare	$63.00
Rate for Payer: Monida Allegiance	$85.50
Rate for Payer: Monida First Choice Health	$87.30
Rate for Payer: Monida Montana Health Co-op	$85.50
Rate for Payer: Monida PacificSource	$85.50

Know your out-of-pocket cost for care.

All Charges