Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

ST SGD EVAL ADD 1/2 HR

Facility

$193.00

Service Code	HCPCS 92608 GN
Hospital Charge Code	6392608
Hospital Revenue Code	440
Min. Negotiated Rate	$135.10
Max. Negotiated Rate	$193.00
Rate for Payer: Aetna Commercial	$183.35
Rate for Payer: Aetna Medicare	$173.70
Rate for Payer: BCBS MT CHIP	$173.70
Rate for Payer: BCBS MT Closed Plan Network	$183.35
Rate for Payer: BCBS MT HealthLink	$173.70
Rate for Payer: BCBS MT Medicare	$173.70
Rate for Payer: BCBS MT POS	$183.35
Rate for Payer: BCBS MT Traditional	$193.00
Rate for Payer: Cash Price	$173.70
Rate for Payer: Cigna Commercial	$183.35
Rate for Payer: Cigna Medicare	$173.70
Rate for Payer: Medicaid All Medicaid	$177.56
Rate for Payer: Medicare All Medicare	$135.10
Rate for Payer: Monida Allegiance	$183.35
Rate for Payer: Monida First Choice Health	$187.21
Rate for Payer: Monida Montana Health Co-op	$183.35
Rate for Payer: Monida PacificSource	$183.35

ST SGD EVAL ADD 1/2 HR

Facility

$193.00

Service Code	HCPCS 92608 GN
Hospital Charge Code	6392608
Hospital Revenue Code	440
Min. Negotiated Rate	$135.10
Max. Negotiated Rate	$193.00
Rate for Payer: Aetna Commercial	$183.35
Rate for Payer: Aetna Medicare	$173.70
Rate for Payer: BCBS MT CHIP	$173.70
Rate for Payer: BCBS MT Closed Plan Network	$183.35
Rate for Payer: BCBS MT HealthLink	$173.70
Rate for Payer: BCBS MT Medicare	$173.70
Rate for Payer: BCBS MT POS	$183.35
Rate for Payer: BCBS MT Traditional	$193.00
Rate for Payer: Cash Price	$173.70
Rate for Payer: Cigna Commercial	$183.35
Rate for Payer: Cigna Medicare	$173.70
Rate for Payer: Medicaid All Medicaid	$177.56
Rate for Payer: Medicare All Medicare	$135.10
Rate for Payer: Monida Allegiance	$183.35
Rate for Payer: Monida First Choice Health	$187.21
Rate for Payer: Monida Montana Health Co-op	$183.35
Rate for Payer: Monida PacificSource	$183.35

ST SGD THERAPY, PRGM MOD

Facility

$180.00

Service Code	HCPCS 92609 GN
Hospital Charge Code	6392609
Hospital Revenue Code	440
Min. Negotiated Rate	$126.00
Max. Negotiated Rate	$180.00
Rate for Payer: Aetna Commercial	$171.00
Rate for Payer: Aetna Medicare	$162.00
Rate for Payer: BCBS MT CHIP	$162.00
Rate for Payer: BCBS MT Closed Plan Network	$171.00
Rate for Payer: BCBS MT HealthLink	$162.00
Rate for Payer: BCBS MT Medicare	$162.00
Rate for Payer: BCBS MT POS	$171.00
Rate for Payer: BCBS MT Traditional	$180.00
Rate for Payer: Cash Price	$162.00
Rate for Payer: Cigna Commercial	$171.00
Rate for Payer: Cigna Medicare	$162.00
Rate for Payer: Medicaid All Medicaid	$165.60
Rate for Payer: Medicare All Medicare	$126.00
Rate for Payer: Monida Allegiance	$171.00
Rate for Payer: Monida First Choice Health	$174.60
Rate for Payer: Monida Montana Health Co-op	$171.00
Rate for Payer: Monida PacificSource	$171.00

ST SGD THERAPY, PRGM MOD

Facility

$180.00

Service Code	HCPCS 92609 GN
Hospital Charge Code	6392609
Hospital Revenue Code	440
Min. Negotiated Rate	$126.00
Max. Negotiated Rate	$180.00
Rate for Payer: Aetna Commercial	$171.00
Rate for Payer: Aetna Medicare	$162.00
Rate for Payer: BCBS MT CHIP	$162.00
Rate for Payer: BCBS MT Closed Plan Network	$171.00
Rate for Payer: BCBS MT HealthLink	$162.00
Rate for Payer: BCBS MT Medicare	$162.00
Rate for Payer: BCBS MT POS	$171.00
Rate for Payer: BCBS MT Traditional	$180.00
Rate for Payer: Cash Price	$162.00
Rate for Payer: Cigna Commercial	$171.00
Rate for Payer: Cigna Medicare	$162.00
Rate for Payer: Medicaid All Medicaid	$165.60
Rate for Payer: Medicare All Medicare	$126.00
Rate for Payer: Monida Allegiance	$171.00
Rate for Payer: Monida First Choice Health	$174.60
Rate for Payer: Monida Montana Health Co-op	$171.00
Rate for Payer: Monida PacificSource	$171.00

ST STD CONGNITIVE PERFORMANCE TEST PER H

Facility

$266.00

Service Code	HCPCS 96125 GN
Hospital Charge Code	6396125
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 STD CONGNITIVE PERFORMANCE TEST PER H

Facility

$266.00

Service Code	HCPCS 96125 GN
Hospital Charge Code	6396125
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 THERAPEUTIC ACTIVITIES

Facility

$109.00

Service Code	HCPCS 97530 GN
Hospital Charge Code	6397530
Hospital Revenue Code	440
Min. Negotiated Rate	$76.30
Max. Negotiated Rate	$109.00
Rate for Payer: Aetna Commercial	$103.55
Rate for Payer: Aetna Medicare	$98.10
Rate for Payer: BCBS MT CHIP	$98.10
Rate for Payer: BCBS MT Closed Plan Network	$103.55
Rate for Payer: BCBS MT HealthLink	$98.10
Rate for Payer: BCBS MT Medicare	$98.10
Rate for Payer: BCBS MT POS	$103.55
Rate for Payer: BCBS MT Traditional	$109.00
Rate for Payer: Cash Price	$98.10
Rate for Payer: Cigna Commercial	$103.55
Rate for Payer: Cigna Medicare	$98.10
Rate for Payer: Medicaid All Medicaid	$100.28
Rate for Payer: Medicare All Medicare	$76.30
Rate for Payer: Monida Allegiance	$103.55
Rate for Payer: Monida First Choice Health	$105.73
Rate for Payer: Monida Montana Health Co-op	$103.55
Rate for Payer: Monida PacificSource	$103.55

ST THERAPEUTIC ACTIVITIES

Facility

$109.00

Service Code	HCPCS 97530 GN
Hospital Charge Code	6397530
Hospital Revenue Code	440
Min. Negotiated Rate	$76.30
Max. Negotiated Rate	$109.00
Rate for Payer: Aetna Commercial	$103.55
Rate for Payer: Aetna Medicare	$98.10
Rate for Payer: BCBS MT CHIP	$98.10
Rate for Payer: BCBS MT Closed Plan Network	$103.55
Rate for Payer: BCBS MT HealthLink	$98.10
Rate for Payer: BCBS MT Medicare	$98.10
Rate for Payer: BCBS MT POS	$103.55
Rate for Payer: BCBS MT Traditional	$109.00
Rate for Payer: Cash Price	$98.10
Rate for Payer: Cigna Commercial	$103.55
Rate for Payer: Cigna Medicare	$98.10
Rate for Payer: Medicaid All Medicaid	$100.28
Rate for Payer: Medicare All Medicare	$76.30
Rate for Payer: Monida Allegiance	$103.55
Rate for Payer: Monida First Choice Health	$105.73
Rate for Payer: Monida Montana Health Co-op	$103.55
Rate for Payer: Monida PacificSource	$103.55

ST THERAPEUTIC EXERCISE

Facility

$106.00

Service Code	HCPCS 97110 GN
Hospital Charge Code	6397110
Hospital Revenue Code	440
Min. Negotiated Rate	$74.20
Max. Negotiated Rate	$106.00
Rate for Payer: Aetna Commercial	$100.70
Rate for Payer: Aetna Medicare	$95.40
Rate for Payer: BCBS MT CHIP	$95.40
Rate for Payer: BCBS MT Closed Plan Network	$100.70
Rate for Payer: BCBS MT HealthLink	$95.40
Rate for Payer: BCBS MT Medicare	$95.40
Rate for Payer: BCBS MT POS	$100.70
Rate for Payer: BCBS MT Traditional	$106.00
Rate for Payer: Cash Price	$95.40
Rate for Payer: Cigna Commercial	$100.70
Rate for Payer: Cigna Medicare	$95.40
Rate for Payer: Medicaid All Medicaid	$97.52
Rate for Payer: Medicare All Medicare	$74.20
Rate for Payer: Monida Allegiance	$100.70
Rate for Payer: Monida First Choice Health	$102.82
Rate for Payer: Monida Montana Health Co-op	$100.70
Rate for Payer: Monida PacificSource	$100.70

ST THERAPEUTIC EXERCISE

Facility

$106.00

Service Code	HCPCS 97110 GN
Hospital Charge Code	6397110
Hospital Revenue Code	440
Min. Negotiated Rate	$74.20
Max. Negotiated Rate	$106.00
Rate for Payer: Aetna Commercial	$100.70
Rate for Payer: Aetna Medicare	$95.40
Rate for Payer: BCBS MT CHIP	$95.40
Rate for Payer: BCBS MT Closed Plan Network	$100.70
Rate for Payer: BCBS MT HealthLink	$95.40
Rate for Payer: BCBS MT Medicare	$95.40
Rate for Payer: BCBS MT POS	$100.70
Rate for Payer: BCBS MT Traditional	$106.00
Rate for Payer: Cash Price	$95.40
Rate for Payer: Cigna Commercial	$100.70
Rate for Payer: Cigna Medicare	$95.40
Rate for Payer: Medicaid All Medicaid	$97.52
Rate for Payer: Medicare All Medicare	$74.20
Rate for Payer: Monida Allegiance	$100.70
Rate for Payer: Monida First Choice Health	$102.82
Rate for Payer: Monida Montana Health Co-op	$100.70
Rate for Payer: Monida PacificSource	$100.70

ST THER INTVENTION COGNI FUNCT 1ST 15MIN

Facility

$71.00

Service Code	HCPCS 97129
Hospital Charge Code	6397129
Hospital Revenue Code	440
Min. Negotiated Rate	$49.70
Max. Negotiated Rate	$71.00
Rate for Payer: Aetna Commercial	$67.45
Rate for Payer: Aetna Medicare	$63.90
Rate for Payer: BCBS MT CHIP	$63.90
Rate for Payer: BCBS MT Closed Plan Network	$67.45
Rate for Payer: BCBS MT HealthLink	$63.90
Rate for Payer: BCBS MT Medicare	$63.90
Rate for Payer: BCBS MT POS	$67.45
Rate for Payer: BCBS MT Traditional	$71.00
Rate for Payer: Cash Price	$63.90
Rate for Payer: Cigna Commercial	$67.45
Rate for Payer: Cigna Medicare	$63.90
Rate for Payer: Medicaid All Medicaid	$65.32
Rate for Payer: Medicare All Medicare	$49.70
Rate for Payer: Monida Allegiance	$67.45
Rate for Payer: Monida First Choice Health	$68.87
Rate for Payer: Monida Montana Health Co-op	$67.45
Rate for Payer: Monida PacificSource	$67.45

ST THER INTVENTION COGNI FUNCT 1ST 15MIN

Facility

$71.00

Service Code	HCPCS 97129
Hospital Charge Code	6397129
Hospital Revenue Code	440
Min. Negotiated Rate	$49.70
Max. Negotiated Rate	$71.00
Rate for Payer: Aetna Commercial	$67.45
Rate for Payer: Aetna Medicare	$63.90
Rate for Payer: BCBS MT CHIP	$63.90
Rate for Payer: BCBS MT Closed Plan Network	$67.45
Rate for Payer: BCBS MT HealthLink	$63.90
Rate for Payer: BCBS MT Medicare	$63.90
Rate for Payer: BCBS MT POS	$67.45
Rate for Payer: BCBS MT Traditional	$71.00
Rate for Payer: Cash Price	$63.90
Rate for Payer: Cigna Commercial	$67.45
Rate for Payer: Cigna Medicare	$63.90
Rate for Payer: Medicaid All Medicaid	$65.32
Rate for Payer: Medicare All Medicare	$49.70
Rate for Payer: Monida Allegiance	$67.45
Rate for Payer: Monida First Choice Health	$68.87
Rate for Payer: Monida Montana Health Co-op	$67.45
Rate for Payer: Monida PacificSource	$67.45

ST THERP INTERVENT EA ADDL 15 MIN

Facility

$65.00

Service Code	HCPCS 97130
Hospital Charge Code	6397130
Hospital Revenue Code	440
Min. Negotiated Rate	$45.50
Max. Negotiated Rate	$65.00
Rate for Payer: Aetna Commercial	$61.75
Rate for Payer: Aetna Medicare	$58.50
Rate for Payer: BCBS MT CHIP	$58.50
Rate for Payer: BCBS MT Closed Plan Network	$61.75
Rate for Payer: BCBS MT HealthLink	$58.50
Rate for Payer: BCBS MT Medicare	$58.50
Rate for Payer: BCBS MT POS	$61.75
Rate for Payer: BCBS MT Traditional	$65.00
Rate for Payer: Cash Price	$58.50
Rate for Payer: Cigna Commercial	$61.75
Rate for Payer: Cigna Medicare	$58.50
Rate for Payer: Medicaid All Medicaid	$59.80
Rate for Payer: Medicare All Medicare	$45.50
Rate for Payer: Monida Allegiance	$61.75
Rate for Payer: Monida First Choice Health	$63.05
Rate for Payer: Monida Montana Health Co-op	$61.75
Rate for Payer: Monida PacificSource	$61.75

ST THERP INTERVENT EA ADDL 15 MIN

Facility

$65.00

Service Code	HCPCS 97130
Hospital Charge Code	6397130
Hospital Revenue Code	440
Min. Negotiated Rate	$45.50
Max. Negotiated Rate	$65.00
Rate for Payer: Aetna Commercial	$61.75
Rate for Payer: Aetna Medicare	$58.50
Rate for Payer: BCBS MT CHIP	$58.50
Rate for Payer: BCBS MT Closed Plan Network	$61.75
Rate for Payer: BCBS MT HealthLink	$58.50
Rate for Payer: BCBS MT Medicare	$58.50
Rate for Payer: BCBS MT POS	$61.75
Rate for Payer: BCBS MT Traditional	$65.00
Rate for Payer: Cash Price	$58.50
Rate for Payer: Cigna Commercial	$61.75
Rate for Payer: Cigna Medicare	$58.50
Rate for Payer: Medicaid All Medicaid	$59.80
Rate for Payer: Medicare All Medicare	$45.50
Rate for Payer: Monida Allegiance	$61.75
Rate for Payer: Monida First Choice Health	$63.05
Rate for Payer: Monida Montana Health Co-op	$61.75
Rate for Payer: Monida PacificSource	$61.75

ST TREATMENT OF SPEECH/LANG (GROUP)

Facility

$161.00

Service Code	HCPCS 92508 GN
Hospital Charge Code	6392508
Hospital Revenue Code	440
Min. Negotiated Rate	$112.70
Max. Negotiated Rate	$161.00
Rate for Payer: Aetna Commercial	$152.95
Rate for Payer: Aetna Medicare	$144.90
Rate for Payer: BCBS MT CHIP	$144.90
Rate for Payer: BCBS MT Closed Plan Network	$152.95
Rate for Payer: BCBS MT HealthLink	$144.90
Rate for Payer: BCBS MT Medicare	$144.90
Rate for Payer: BCBS MT POS	$152.95
Rate for Payer: BCBS MT Traditional	$161.00
Rate for Payer: Cash Price	$144.90
Rate for Payer: Cigna Commercial	$152.95
Rate for Payer: Cigna Medicare	$144.90
Rate for Payer: Medicaid All Medicaid	$148.12
Rate for Payer: Medicare All Medicare	$112.70
Rate for Payer: Monida Allegiance	$152.95
Rate for Payer: Monida First Choice Health	$156.17
Rate for Payer: Monida Montana Health Co-op	$152.95
Rate for Payer: Monida PacificSource	$152.95

ST TREATMENT OF SPEECH/LANG (GROUP)

Facility

$161.00

Service Code	HCPCS 92508 GN
Hospital Charge Code	6392508
Hospital Revenue Code	440
Min. Negotiated Rate	$112.70
Max. Negotiated Rate	$161.00
Rate for Payer: Aetna Commercial	$152.95
Rate for Payer: Aetna Medicare	$144.90
Rate for Payer: BCBS MT CHIP	$144.90
Rate for Payer: BCBS MT Closed Plan Network	$152.95
Rate for Payer: BCBS MT HealthLink	$144.90
Rate for Payer: BCBS MT Medicare	$144.90
Rate for Payer: BCBS MT POS	$152.95
Rate for Payer: BCBS MT Traditional	$161.00
Rate for Payer: Cash Price	$144.90
Rate for Payer: Cigna Commercial	$152.95
Rate for Payer: Cigna Medicare	$144.90
Rate for Payer: Medicaid All Medicaid	$148.12
Rate for Payer: Medicare All Medicare	$112.70
Rate for Payer: Monida Allegiance	$152.95
Rate for Payer: Monida First Choice Health	$156.17
Rate for Payer: Monida Montana Health Co-op	$152.95
Rate for Payer: Monida PacificSource	$152.95

ST TREATMENT OF SPEECH/LANG (INDIV)

Facility

$285.00

Service Code	HCPCS 92507 GN
Hospital Charge Code	6392507
Hospital Revenue Code	440
Min. Negotiated Rate	$199.50
Max. Negotiated Rate	$285.00
Rate for Payer: Aetna Commercial	$270.75
Rate for Payer: Aetna Medicare	$256.50
Rate for Payer: BCBS MT CHIP	$256.50
Rate for Payer: BCBS MT Closed Plan Network	$270.75
Rate for Payer: BCBS MT HealthLink	$256.50
Rate for Payer: BCBS MT Medicare	$256.50
Rate for Payer: BCBS MT POS	$270.75
Rate for Payer: BCBS MT Traditional	$285.00
Rate for Payer: Cash Price	$256.50
Rate for Payer: Cigna Commercial	$270.75
Rate for Payer: Cigna Medicare	$256.50
Rate for Payer: Medicaid All Medicaid	$262.20
Rate for Payer: Medicare All Medicare	$199.50
Rate for Payer: Monida Allegiance	$270.75
Rate for Payer: Monida First Choice Health	$276.45
Rate for Payer: Monida Montana Health Co-op	$270.75
Rate for Payer: Monida PacificSource	$270.75

ST TREATMENT OF SPEECH/LANG (INDIV)

Facility

$285.00

Service Code	HCPCS 92507 GN
Hospital Charge Code	6392507
Hospital Revenue Code	440
Min. Negotiated Rate	$199.50
Max. Negotiated Rate	$285.00
Rate for Payer: Aetna Commercial	$270.75
Rate for Payer: Aetna Medicare	$256.50
Rate for Payer: BCBS MT CHIP	$256.50
Rate for Payer: BCBS MT Closed Plan Network	$270.75
Rate for Payer: BCBS MT HealthLink	$256.50
Rate for Payer: BCBS MT Medicare	$256.50
Rate for Payer: BCBS MT POS	$270.75
Rate for Payer: BCBS MT Traditional	$285.00
Rate for Payer: Cash Price	$256.50
Rate for Payer: Cigna Commercial	$270.75
Rate for Payer: Cigna Medicare	$256.50
Rate for Payer: Medicaid All Medicaid	$262.20
Rate for Payer: Medicare All Medicare	$199.50
Rate for Payer: Monida Allegiance	$270.75
Rate for Payer: Monida First Choice Health	$276.45
Rate for Payer: Monida Montana Health Co-op	$270.75
Rate for Payer: Monida PacificSource	$270.75

ST TREATMENT OF SWALLOWING DYSF

Facility

$286.00

Service Code	HCPCS 92526 GN
Hospital Charge Code	6392526
Hospital Revenue Code	440
Min. Negotiated Rate	$200.20
Max. Negotiated Rate	$286.00
Rate for Payer: Aetna Commercial	$271.70
Rate for Payer: Aetna Medicare	$257.40
Rate for Payer: BCBS MT CHIP	$257.40
Rate for Payer: BCBS MT Closed Plan Network	$271.70
Rate for Payer: BCBS MT HealthLink	$257.40
Rate for Payer: BCBS MT Medicare	$257.40
Rate for Payer: BCBS MT POS	$271.70
Rate for Payer: BCBS MT Traditional	$286.00
Rate for Payer: Cash Price	$257.40
Rate for Payer: Cigna Commercial	$271.70
Rate for Payer: Cigna Medicare	$257.40
Rate for Payer: Medicaid All Medicaid	$263.12
Rate for Payer: Medicare All Medicare	$200.20
Rate for Payer: Monida Allegiance	$271.70
Rate for Payer: Monida First Choice Health	$277.42
Rate for Payer: Monida Montana Health Co-op	$271.70
Rate for Payer: Monida PacificSource	$271.70

ST TREATMENT OF SWALLOWING DYSF

Facility

$286.00

Service Code	HCPCS 92526 GN
Hospital Charge Code	6392526
Hospital Revenue Code	440
Min. Negotiated Rate	$200.20
Max. Negotiated Rate	$286.00
Rate for Payer: Aetna Commercial	$271.70
Rate for Payer: Aetna Medicare	$257.40
Rate for Payer: BCBS MT CHIP	$257.40
Rate for Payer: BCBS MT Closed Plan Network	$271.70
Rate for Payer: BCBS MT HealthLink	$257.40
Rate for Payer: BCBS MT Medicare	$257.40
Rate for Payer: BCBS MT POS	$271.70
Rate for Payer: BCBS MT Traditional	$286.00
Rate for Payer: Cash Price	$257.40
Rate for Payer: Cigna Commercial	$271.70
Rate for Payer: Cigna Medicare	$257.40
Rate for Payer: Medicaid All Medicaid	$263.12
Rate for Payer: Medicare All Medicare	$200.20
Rate for Payer: Monida Allegiance	$271.70
Rate for Payer: Monida First Choice Health	$277.42
Rate for Payer: Monida Montana Health Co-op	$271.70
Rate for Payer: Monida PacificSource	$271.70

ST VIDEO STUDY MOTION FLUOROSCOPIC EVAL

Facility

$796.00

Service Code	HCPCS 92611 GN
Hospital Charge Code	6392611
Hospital Revenue Code	440
Min. Negotiated Rate	$557.20
Max. Negotiated Rate	$796.00
Rate for Payer: Aetna Commercial	$756.20
Rate for Payer: Aetna Medicare	$716.40
Rate for Payer: BCBS MT CHIP	$716.40
Rate for Payer: BCBS MT Closed Plan Network	$756.20
Rate for Payer: BCBS MT HealthLink	$716.40
Rate for Payer: BCBS MT Medicare	$716.40
Rate for Payer: BCBS MT POS	$756.20
Rate for Payer: BCBS MT Traditional	$796.00
Rate for Payer: Cash Price	$716.40
Rate for Payer: Cigna Commercial	$756.20
Rate for Payer: Cigna Medicare	$716.40
Rate for Payer: Medicaid All Medicaid	$732.32
Rate for Payer: Medicare All Medicare	$557.20
Rate for Payer: Monida Allegiance	$756.20
Rate for Payer: Monida First Choice Health	$772.12
Rate for Payer: Monida Montana Health Co-op	$756.20
Rate for Payer: Monida PacificSource	$756.20

ST VIDEO STUDY MOTION FLUOROSCOPIC EVAL

Facility

$796.00

Service Code	HCPCS 92611 GN
Hospital Charge Code	6392611
Hospital Revenue Code	440
Min. Negotiated Rate	$557.20
Max. Negotiated Rate	$796.00
Rate for Payer: Aetna Commercial	$756.20
Rate for Payer: Aetna Medicare	$716.40
Rate for Payer: BCBS MT CHIP	$716.40
Rate for Payer: BCBS MT Closed Plan Network	$756.20
Rate for Payer: BCBS MT HealthLink	$716.40
Rate for Payer: BCBS MT Medicare	$716.40
Rate for Payer: BCBS MT POS	$756.20
Rate for Payer: BCBS MT Traditional	$796.00
Rate for Payer: Cash Price	$716.40
Rate for Payer: Cigna Commercial	$756.20
Rate for Payer: Cigna Medicare	$716.40
Rate for Payer: Medicaid All Medicaid	$732.32
Rate for Payer: Medicare All Medicare	$557.20
Rate for Payer: Monida Allegiance	$756.20
Rate for Payer: Monida First Choice Health	$772.12
Rate for Payer: Monida Montana Health Co-op	$756.20
Rate for Payer: Monida PacificSource	$756.20

SUCRALFATE TAB [1 GM]

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	3000435
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

SUCRALFATE TAB [1 GM]

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	3000435
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

SUCTION CATHETER 6FR

Facility

$18.00

Hospital Charge Code	80030298
Hospital Revenue Code	270
Min. Negotiated Rate	$12.60
Max. Negotiated Rate	$18.00
Rate for Payer: Aetna Commercial	$17.10
Rate for Payer: Aetna Medicare	$16.20
Rate for Payer: BCBS MT CHIP	$16.20
Rate for Payer: BCBS MT Closed Plan Network	$17.10
Rate for Payer: BCBS MT HealthLink	$16.20
Rate for Payer: BCBS MT Medicare	$16.20
Rate for Payer: BCBS MT POS	$17.10
Rate for Payer: BCBS MT Traditional	$18.00
Rate for Payer: Cash Price	$16.20
Rate for Payer: Cigna Commercial	$17.10
Rate for Payer: Cigna Medicare	$16.20
Rate for Payer: Medicaid All Medicaid	$16.56
Rate for Payer: Medicare All Medicare	$12.60
Rate for Payer: Monida Allegiance	$17.10
Rate for Payer: Monida First Choice Health	$17.46
Rate for Payer: Monida Montana Health Co-op	$17.10
Rate for Payer: Monida PacificSource	$17.10

Know your out-of-pocket cost for care.

All Charges