Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

TX DISLOC JT W/O ANES W/MANIP CLO

Facility

$606.00

Hospital Charge Code	8126770
Hospital Revenue Code	520
Min. Negotiated Rate	$424.20
Max. Negotiated Rate	$606.00
Rate for Payer: Aetna Commercial	$575.70
Rate for Payer: Aetna Medicare	$545.40
Rate for Payer: BCBS MT CHIP	$545.40
Rate for Payer: BCBS MT Closed Plan Network	$575.70
Rate for Payer: BCBS MT HealthLink	$545.40
Rate for Payer: BCBS MT Medicare	$545.40
Rate for Payer: BCBS MT POS	$575.70
Rate for Payer: BCBS MT Traditional	$606.00
Rate for Payer: Cash Price	$545.40
Rate for Payer: Cigna Commercial	$575.70
Rate for Payer: Cigna Medicare	$545.40
Rate for Payer: Medicaid All Medicaid	$557.52
Rate for Payer: Medicare All Medicare	$424.20
Rate for Payer: Monida Allegiance	$575.70
Rate for Payer: Monida First Choice Health	$587.82
Rate for Payer: Monida Montana Health Co-op	$575.70
Rate for Payer: Monida PacificSource	$575.70

TX DISLOC JT W/O ANES W/MANIP CLO

Facility

$606.00

Hospital Charge Code	8126770
Hospital Revenue Code	520
Min. Negotiated Rate	$424.20
Max. Negotiated Rate	$606.00
Rate for Payer: Aetna Commercial	$575.70
Rate for Payer: Aetna Medicare	$545.40
Rate for Payer: BCBS MT CHIP	$545.40
Rate for Payer: BCBS MT Closed Plan Network	$575.70
Rate for Payer: BCBS MT HealthLink	$545.40
Rate for Payer: BCBS MT Medicare	$545.40
Rate for Payer: BCBS MT POS	$575.70
Rate for Payer: BCBS MT Traditional	$606.00
Rate for Payer: Cash Price	$545.40
Rate for Payer: Cigna Commercial	$575.70
Rate for Payer: Cigna Medicare	$545.40
Rate for Payer: Medicaid All Medicaid	$557.52
Rate for Payer: Medicare All Medicare	$424.20
Rate for Payer: Monida Allegiance	$575.70
Rate for Payer: Monida First Choice Health	$587.82
Rate for Payer: Monida Montana Health Co-op	$575.70
Rate for Payer: Monida PacificSource	$575.70

UNLISTED PROC, NERVOUS SYSTEM 64999

Facility

$1,498.00

Service Code	HCPCS 64999
Hospital Charge Code	1564999
Hospital Revenue Code	761
Min. Negotiated Rate	$1,048.60
Max. Negotiated Rate	$1,498.00
Rate for Payer: Aetna Commercial	$1,423.10
Rate for Payer: Aetna Medicare	$1,348.20
Rate for Payer: BCBS MT CHIP	$1,348.20
Rate for Payer: BCBS MT Closed Plan Network	$1,423.10
Rate for Payer: BCBS MT HealthLink	$1,348.20
Rate for Payer: BCBS MT Medicare	$1,348.20
Rate for Payer: BCBS MT POS	$1,423.10
Rate for Payer: BCBS MT Traditional	$1,498.00
Rate for Payer: Cash Price	$1,348.20
Rate for Payer: Cigna Commercial	$1,423.10
Rate for Payer: Cigna Medicare	$1,348.20
Rate for Payer: Medicaid All Medicaid	$1,378.16
Rate for Payer: Medicare All Medicare	$1,048.60
Rate for Payer: Monida Allegiance	$1,423.10
Rate for Payer: Monida First Choice Health	$1,453.06
Rate for Payer: Monida Montana Health Co-op	$1,423.10
Rate for Payer: Monida PacificSource	$1,423.10

UNLISTED PROC, NERVOUS SYSTEM 64999

Facility

$1,498.00

Service Code	HCPCS 64999
Hospital Charge Code	1564999
Hospital Revenue Code	761
Min. Negotiated Rate	$1,048.60
Max. Negotiated Rate	$1,498.00
Rate for Payer: Aetna Commercial	$1,423.10
Rate for Payer: Aetna Medicare	$1,348.20
Rate for Payer: BCBS MT CHIP	$1,348.20
Rate for Payer: BCBS MT Closed Plan Network	$1,423.10
Rate for Payer: BCBS MT HealthLink	$1,348.20
Rate for Payer: BCBS MT Medicare	$1,348.20
Rate for Payer: BCBS MT POS	$1,423.10
Rate for Payer: BCBS MT Traditional	$1,498.00
Rate for Payer: Cash Price	$1,348.20
Rate for Payer: Cigna Commercial	$1,423.10
Rate for Payer: Cigna Medicare	$1,348.20
Rate for Payer: Medicaid All Medicaid	$1,378.16
Rate for Payer: Medicare All Medicare	$1,048.60
Rate for Payer: Monida Allegiance	$1,423.10
Rate for Payer: Monida First Choice Health	$1,453.06
Rate for Payer: Monida Montana Health Co-op	$1,423.10
Rate for Payer: Monida PacificSource	$1,423.10

UNLISTED PSYCIATRIC PRO/THERAPY

Facility

$240.00

Service Code	HCPCS 90899
Hospital Charge Code	8090899
Hospital Revenue Code	900
Min. Negotiated Rate	$168.00
Max. Negotiated Rate	$240.00
Rate for Payer: Aetna Commercial	$228.00
Rate for Payer: Aetna Medicare	$216.00
Rate for Payer: BCBS MT CHIP	$216.00
Rate for Payer: BCBS MT Closed Plan Network	$228.00
Rate for Payer: BCBS MT HealthLink	$216.00
Rate for Payer: BCBS MT Medicare	$216.00
Rate for Payer: BCBS MT POS	$228.00
Rate for Payer: BCBS MT Traditional	$240.00
Rate for Payer: Cash Price	$216.00
Rate for Payer: Cigna Commercial	$228.00
Rate for Payer: Cigna Medicare	$216.00
Rate for Payer: Medicaid All Medicaid	$220.80
Rate for Payer: Medicare All Medicare	$168.00
Rate for Payer: Monida Allegiance	$228.00
Rate for Payer: Monida First Choice Health	$232.80
Rate for Payer: Monida Montana Health Co-op	$228.00
Rate for Payer: Monida PacificSource	$228.00

UNLISTED PSYCIATRIC PRO/THERAPY

Facility

$240.00

Service Code	HCPCS 90899
Hospital Charge Code	8090899
Hospital Revenue Code	900
Min. Negotiated Rate	$168.00
Max. Negotiated Rate	$240.00
Rate for Payer: Aetna Commercial	$228.00
Rate for Payer: Aetna Medicare	$216.00
Rate for Payer: BCBS MT CHIP	$216.00
Rate for Payer: BCBS MT Closed Plan Network	$228.00
Rate for Payer: BCBS MT HealthLink	$216.00
Rate for Payer: BCBS MT Medicare	$216.00
Rate for Payer: BCBS MT POS	$228.00
Rate for Payer: BCBS MT Traditional	$240.00
Rate for Payer: Cash Price	$216.00
Rate for Payer: Cigna Commercial	$228.00
Rate for Payer: Cigna Medicare	$216.00
Rate for Payer: Medicaid All Medicaid	$220.80
Rate for Payer: Medicare All Medicare	$168.00
Rate for Payer: Monida Allegiance	$228.00
Rate for Payer: Monida First Choice Health	$232.80
Rate for Payer: Monida Montana Health Co-op	$228.00
Rate for Payer: Monida PacificSource	$228.00

UNNA BOOT BANDAGE 3''

Facility

$57.00

Hospital Charge Code	80030445
Hospital Revenue Code	270
Min. Negotiated Rate	$39.90
Max. Negotiated Rate	$57.00
Rate for Payer: Aetna Commercial	$54.15
Rate for Payer: Aetna Medicare	$51.30
Rate for Payer: BCBS MT CHIP	$51.30
Rate for Payer: BCBS MT Closed Plan Network	$54.15
Rate for Payer: BCBS MT HealthLink	$51.30
Rate for Payer: BCBS MT Medicare	$51.30
Rate for Payer: BCBS MT POS	$54.15
Rate for Payer: BCBS MT Traditional	$57.00
Rate for Payer: Cash Price	$51.30
Rate for Payer: Cigna Commercial	$54.15
Rate for Payer: Cigna Medicare	$51.30
Rate for Payer: Medicaid All Medicaid	$52.44
Rate for Payer: Medicare All Medicare	$39.90
Rate for Payer: Monida Allegiance	$54.15
Rate for Payer: Monida First Choice Health	$55.29
Rate for Payer: Monida Montana Health Co-op	$54.15
Rate for Payer: Monida PacificSource	$54.15

UNNA BOOT BANDAGE 3''

Facility

$57.00

Hospital Charge Code	80030445
Hospital Revenue Code	270
Min. Negotiated Rate	$39.90
Max. Negotiated Rate	$57.00
Rate for Payer: Aetna Commercial	$54.15
Rate for Payer: Aetna Medicare	$51.30
Rate for Payer: BCBS MT CHIP	$51.30
Rate for Payer: BCBS MT Closed Plan Network	$54.15
Rate for Payer: BCBS MT HealthLink	$51.30
Rate for Payer: BCBS MT Medicare	$51.30
Rate for Payer: BCBS MT POS	$54.15
Rate for Payer: BCBS MT Traditional	$57.00
Rate for Payer: Cash Price	$51.30
Rate for Payer: Cigna Commercial	$54.15
Rate for Payer: Cigna Medicare	$51.30
Rate for Payer: Medicaid All Medicaid	$52.44
Rate for Payer: Medicare All Medicare	$39.90
Rate for Payer: Monida Allegiance	$54.15
Rate for Payer: Monida First Choice Health	$55.29
Rate for Payer: Monida Montana Health Co-op	$54.15
Rate for Payer: Monida PacificSource	$54.15

URETHRAL CATHETER TRAY ( STRAIGHT CATH)

Facility

$27.00

Hospital Charge Code	80030068
Hospital Revenue Code	270
Min. Negotiated Rate	$18.90
Max. Negotiated Rate	$27.00
Rate for Payer: Aetna Commercial	$25.65
Rate for Payer: Aetna Medicare	$24.30
Rate for Payer: BCBS MT CHIP	$24.30
Rate for Payer: BCBS MT Closed Plan Network	$25.65
Rate for Payer: BCBS MT HealthLink	$24.30
Rate for Payer: BCBS MT Medicare	$24.30
Rate for Payer: BCBS MT POS	$25.65
Rate for Payer: BCBS MT Traditional	$27.00
Rate for Payer: Cash Price	$24.30
Rate for Payer: Cigna Commercial	$25.65
Rate for Payer: Cigna Medicare	$24.30
Rate for Payer: Medicaid All Medicaid	$24.84
Rate for Payer: Medicare All Medicare	$18.90
Rate for Payer: Monida Allegiance	$25.65
Rate for Payer: Monida First Choice Health	$26.19
Rate for Payer: Monida Montana Health Co-op	$25.65
Rate for Payer: Monida PacificSource	$25.65

URETHRAL CATHETER TRAY ( STRAIGHT CATH)

Facility

$27.00

Hospital Charge Code	80030068
Hospital Revenue Code	270
Min. Negotiated Rate	$18.90
Max. Negotiated Rate	$27.00
Rate for Payer: Aetna Commercial	$25.65
Rate for Payer: Aetna Medicare	$24.30
Rate for Payer: BCBS MT CHIP	$24.30
Rate for Payer: BCBS MT Closed Plan Network	$25.65
Rate for Payer: BCBS MT HealthLink	$24.30
Rate for Payer: BCBS MT Medicare	$24.30
Rate for Payer: BCBS MT POS	$25.65
Rate for Payer: BCBS MT Traditional	$27.00
Rate for Payer: Cash Price	$24.30
Rate for Payer: Cigna Commercial	$25.65
Rate for Payer: Cigna Medicare	$24.30
Rate for Payer: Medicaid All Medicaid	$24.84
Rate for Payer: Medicare All Medicare	$18.90
Rate for Payer: Monida Allegiance	$25.65
Rate for Payer: Monida First Choice Health	$26.19
Rate for Payer: Monida Montana Health Co-op	$25.65
Rate for Payer: Monida PacificSource	$25.65

URETHRAL CATH KIT

Facility

$53.00

Hospital Charge Code	80030430
Hospital Revenue Code	270
Min. Negotiated Rate	$37.10
Max. Negotiated Rate	$53.00
Rate for Payer: Aetna Commercial	$50.35
Rate for Payer: Aetna Medicare	$47.70
Rate for Payer: BCBS MT CHIP	$47.70
Rate for Payer: BCBS MT Closed Plan Network	$50.35
Rate for Payer: BCBS MT HealthLink	$47.70
Rate for Payer: BCBS MT Medicare	$47.70
Rate for Payer: BCBS MT POS	$50.35
Rate for Payer: BCBS MT Traditional	$53.00
Rate for Payer: Cash Price	$47.70
Rate for Payer: Cigna Commercial	$50.35
Rate for Payer: Cigna Medicare	$47.70
Rate for Payer: Medicaid All Medicaid	$48.76
Rate for Payer: Medicare All Medicare	$37.10
Rate for Payer: Monida Allegiance	$50.35
Rate for Payer: Monida First Choice Health	$51.41
Rate for Payer: Monida Montana Health Co-op	$50.35
Rate for Payer: Monida PacificSource	$50.35

URETHRAL CATH KIT

Facility

$53.00

Hospital Charge Code	80030430
Hospital Revenue Code	270
Min. Negotiated Rate	$37.10
Max. Negotiated Rate	$53.00
Rate for Payer: Aetna Commercial	$50.35
Rate for Payer: Aetna Medicare	$47.70
Rate for Payer: BCBS MT CHIP	$47.70
Rate for Payer: BCBS MT Closed Plan Network	$50.35
Rate for Payer: BCBS MT HealthLink	$47.70
Rate for Payer: BCBS MT Medicare	$47.70
Rate for Payer: BCBS MT POS	$50.35
Rate for Payer: BCBS MT Traditional	$53.00
Rate for Payer: Cash Price	$47.70
Rate for Payer: Cigna Commercial	$50.35
Rate for Payer: Cigna Medicare	$47.70
Rate for Payer: Medicaid All Medicaid	$48.76
Rate for Payer: Medicare All Medicare	$37.10
Rate for Payer: Monida Allegiance	$50.35
Rate for Payer: Monida First Choice Health	$51.41
Rate for Payer: Monida Montana Health Co-op	$50.35
Rate for Payer: Monida PacificSource	$50.35

URIC ACID

Facility

$68.00

Service Code	HCPCS 84550
Hospital Charge Code	4084550
Hospital Revenue Code	301
Min. Negotiated Rate	$47.60
Max. Negotiated Rate	$68.00
Rate for Payer: Aetna Commercial	$64.60
Rate for Payer: Aetna Medicare	$61.20
Rate for Payer: BCBS MT CHIP	$61.20
Rate for Payer: BCBS MT Closed Plan Network	$64.60
Rate for Payer: BCBS MT HealthLink	$61.20
Rate for Payer: BCBS MT Medicare	$61.20
Rate for Payer: BCBS MT POS	$64.60
Rate for Payer: BCBS MT Traditional	$68.00
Rate for Payer: Cash Price	$61.20
Rate for Payer: Cigna Commercial	$64.60
Rate for Payer: Cigna Medicare	$61.20
Rate for Payer: Medicaid All Medicaid	$62.56
Rate for Payer: Medicare All Medicare	$47.60
Rate for Payer: Monida Allegiance	$64.60
Rate for Payer: Monida First Choice Health	$65.96
Rate for Payer: Monida Montana Health Co-op	$64.60
Rate for Payer: Monida PacificSource	$64.60

URIC ACID

Facility

$68.00

Service Code	HCPCS 84550
Hospital Charge Code	4084550
Hospital Revenue Code	301
Min. Negotiated Rate	$47.60
Max. Negotiated Rate	$68.00
Rate for Payer: Aetna Commercial	$64.60
Rate for Payer: Aetna Medicare	$61.20
Rate for Payer: BCBS MT CHIP	$61.20
Rate for Payer: BCBS MT Closed Plan Network	$64.60
Rate for Payer: BCBS MT HealthLink	$61.20
Rate for Payer: BCBS MT Medicare	$61.20
Rate for Payer: BCBS MT POS	$64.60
Rate for Payer: BCBS MT Traditional	$68.00
Rate for Payer: Cash Price	$61.20
Rate for Payer: Cigna Commercial	$64.60
Rate for Payer: Cigna Medicare	$61.20
Rate for Payer: Medicaid All Medicaid	$62.56
Rate for Payer: Medicare All Medicare	$47.60
Rate for Payer: Monida Allegiance	$64.60
Rate for Payer: Monida First Choice Health	$65.96
Rate for Payer: Monida Montana Health Co-op	$64.60
Rate for Payer: Monida PacificSource	$64.60

.URINALYSIS, DIPSTICK

Facility

$48.00

Service Code	HCPCS 81003
Hospital Charge Code	4081003
Hospital Revenue Code	307
Min. Negotiated Rate	$33.60
Max. Negotiated Rate	$48.00
Rate for Payer: Aetna Commercial	$45.60
Rate for Payer: Aetna Medicare	$43.20
Rate for Payer: BCBS MT CHIP	$43.20
Rate for Payer: BCBS MT Closed Plan Network	$45.60
Rate for Payer: BCBS MT HealthLink	$43.20
Rate for Payer: BCBS MT Medicare	$43.20
Rate for Payer: BCBS MT POS	$45.60
Rate for Payer: BCBS MT Traditional	$48.00
Rate for Payer: Cash Price	$43.20
Rate for Payer: Cigna Commercial	$45.60
Rate for Payer: Cigna Medicare	$43.20
Rate for Payer: Medicaid All Medicaid	$44.16
Rate for Payer: Medicare All Medicare	$33.60
Rate for Payer: Monida Allegiance	$45.60
Rate for Payer: Monida First Choice Health	$46.56
Rate for Payer: Monida Montana Health Co-op	$45.60
Rate for Payer: Monida PacificSource	$45.60

.URINALYSIS, DIPSTICK

Facility

$48.00

Service Code	HCPCS 81003
Hospital Charge Code	4081003
Hospital Revenue Code	307
Min. Negotiated Rate	$33.60
Max. Negotiated Rate	$48.00
Rate for Payer: Aetna Commercial	$45.60
Rate for Payer: Aetna Medicare	$43.20
Rate for Payer: BCBS MT CHIP	$43.20
Rate for Payer: BCBS MT Closed Plan Network	$45.60
Rate for Payer: BCBS MT HealthLink	$43.20
Rate for Payer: BCBS MT Medicare	$43.20
Rate for Payer: BCBS MT POS	$45.60
Rate for Payer: BCBS MT Traditional	$48.00
Rate for Payer: Cash Price	$43.20
Rate for Payer: Cigna Commercial	$45.60
Rate for Payer: Cigna Medicare	$43.20
Rate for Payer: Medicaid All Medicaid	$44.16
Rate for Payer: Medicare All Medicare	$33.60
Rate for Payer: Monida Allegiance	$45.60
Rate for Payer: Monida First Choice Health	$46.56
Rate for Payer: Monida Montana Health Co-op	$45.60
Rate for Payer: Monida PacificSource	$45.60

.URINALYSIS, DIPSTICK AND MICROSCOPIC

Facility

$69.00

Service Code	HCPCS 81001
Hospital Charge Code	4081001
Hospital Revenue Code	300
Min. Negotiated Rate	$48.30
Max. Negotiated Rate	$69.00
Rate for Payer: Aetna Commercial	$65.55
Rate for Payer: Aetna Medicare	$62.10
Rate for Payer: BCBS MT CHIP	$62.10
Rate for Payer: BCBS MT Closed Plan Network	$65.55
Rate for Payer: BCBS MT HealthLink	$62.10
Rate for Payer: BCBS MT Medicare	$62.10
Rate for Payer: BCBS MT POS	$65.55
Rate for Payer: BCBS MT Traditional	$69.00
Rate for Payer: Cash Price	$62.10
Rate for Payer: Cigna Commercial	$65.55
Rate for Payer: Cigna Medicare	$62.10
Rate for Payer: Medicaid All Medicaid	$63.48
Rate for Payer: Medicare All Medicare	$48.30
Rate for Payer: Monida Allegiance	$65.55
Rate for Payer: Monida First Choice Health	$66.93
Rate for Payer: Monida Montana Health Co-op	$65.55
Rate for Payer: Monida PacificSource	$65.55

.URINALYSIS, DIPSTICK AND MICROSCOPIC

Facility

$69.00

Service Code	HCPCS 81001
Hospital Charge Code	4081001
Hospital Revenue Code	300
Min. Negotiated Rate	$48.30
Max. Negotiated Rate	$69.00
Rate for Payer: Aetna Commercial	$65.55
Rate for Payer: Aetna Medicare	$62.10
Rate for Payer: BCBS MT CHIP	$62.10
Rate for Payer: BCBS MT Closed Plan Network	$65.55
Rate for Payer: BCBS MT HealthLink	$62.10
Rate for Payer: BCBS MT Medicare	$62.10
Rate for Payer: BCBS MT POS	$65.55
Rate for Payer: BCBS MT Traditional	$69.00
Rate for Payer: Cash Price	$62.10
Rate for Payer: Cigna Commercial	$65.55
Rate for Payer: Cigna Medicare	$62.10
Rate for Payer: Medicaid All Medicaid	$63.48
Rate for Payer: Medicare All Medicare	$48.30
Rate for Payer: Monida Allegiance	$65.55
Rate for Payer: Monida First Choice Health	$66.93
Rate for Payer: Monida Montana Health Co-op	$65.55
Rate for Payer: Monida PacificSource	$65.55

URINALYSIS, DIPSTICK - RVMC

Facility

$38.00

Service Code	HCPCS 81003
Hospital Charge Code	8081003
Hospital Revenue Code	307
Min. Negotiated Rate	$26.60
Max. Negotiated Rate	$38.00
Rate for Payer: Aetna Commercial	$36.10
Rate for Payer: Aetna Medicare	$34.20
Rate for Payer: BCBS MT CHIP	$34.20
Rate for Payer: BCBS MT Closed Plan Network	$36.10
Rate for Payer: BCBS MT HealthLink	$34.20
Rate for Payer: BCBS MT Medicare	$34.20
Rate for Payer: BCBS MT POS	$36.10
Rate for Payer: BCBS MT Traditional	$38.00
Rate for Payer: Cash Price	$34.20
Rate for Payer: Cigna Commercial	$36.10
Rate for Payer: Cigna Medicare	$34.20
Rate for Payer: Medicaid All Medicaid	$34.96
Rate for Payer: Medicare All Medicare	$26.60
Rate for Payer: Monida Allegiance	$36.10
Rate for Payer: Monida First Choice Health	$36.86
Rate for Payer: Monida Montana Health Co-op	$36.10
Rate for Payer: Monida PacificSource	$36.10

URINALYSIS, DIPSTICK - RVMC

Facility

$38.00

Service Code	HCPCS 81003
Hospital Charge Code	8081003
Hospital Revenue Code	307
Min. Negotiated Rate	$26.60
Max. Negotiated Rate	$38.00
Rate for Payer: Aetna Commercial	$36.10
Rate for Payer: Aetna Medicare	$34.20
Rate for Payer: BCBS MT CHIP	$34.20
Rate for Payer: BCBS MT Closed Plan Network	$36.10
Rate for Payer: BCBS MT HealthLink	$34.20
Rate for Payer: BCBS MT Medicare	$34.20
Rate for Payer: BCBS MT POS	$36.10
Rate for Payer: BCBS MT Traditional	$38.00
Rate for Payer: Cash Price	$34.20
Rate for Payer: Cigna Commercial	$36.10
Rate for Payer: Cigna Medicare	$34.20
Rate for Payer: Medicaid All Medicaid	$34.96
Rate for Payer: Medicare All Medicare	$26.60
Rate for Payer: Monida Allegiance	$36.10
Rate for Payer: Monida First Choice Health	$36.86
Rate for Payer: Monida Montana Health Co-op	$36.10
Rate for Payer: Monida PacificSource	$36.10

URINALYSIS, DIPSTICK - TWIN BRIDGES

Facility

$38.00

Service Code	HCPCS 81003
Hospital Charge Code	8181003
Hospital Revenue Code	307
Min. Negotiated Rate	$26.60
Max. Negotiated Rate	$38.00
Rate for Payer: Aetna Commercial	$36.10
Rate for Payer: Aetna Medicare	$34.20
Rate for Payer: BCBS MT CHIP	$34.20
Rate for Payer: BCBS MT Closed Plan Network	$36.10
Rate for Payer: BCBS MT HealthLink	$34.20
Rate for Payer: BCBS MT Medicare	$34.20
Rate for Payer: BCBS MT POS	$36.10
Rate for Payer: BCBS MT Traditional	$38.00
Rate for Payer: Cash Price	$34.20
Rate for Payer: Cigna Commercial	$36.10
Rate for Payer: Cigna Medicare	$34.20
Rate for Payer: Medicaid All Medicaid	$34.96
Rate for Payer: Medicare All Medicare	$26.60
Rate for Payer: Monida Allegiance	$36.10
Rate for Payer: Monida First Choice Health	$36.86
Rate for Payer: Monida Montana Health Co-op	$36.10
Rate for Payer: Monida PacificSource	$36.10

URINALYSIS, DIPSTICK - TWIN BRIDGES

Facility

$38.00

Service Code	HCPCS 81003
Hospital Charge Code	8181003
Hospital Revenue Code	307
Min. Negotiated Rate	$26.60
Max. Negotiated Rate	$38.00
Rate for Payer: Aetna Commercial	$36.10
Rate for Payer: Aetna Medicare	$34.20
Rate for Payer: BCBS MT CHIP	$34.20
Rate for Payer: BCBS MT Closed Plan Network	$36.10
Rate for Payer: BCBS MT HealthLink	$34.20
Rate for Payer: BCBS MT Medicare	$34.20
Rate for Payer: BCBS MT POS	$36.10
Rate for Payer: BCBS MT Traditional	$38.00
Rate for Payer: Cash Price	$34.20
Rate for Payer: Cigna Commercial	$36.10
Rate for Payer: Cigna Medicare	$34.20
Rate for Payer: Medicaid All Medicaid	$34.96
Rate for Payer: Medicare All Medicare	$26.60
Rate for Payer: Monida Allegiance	$36.10
Rate for Payer: Monida First Choice Health	$36.86
Rate for Payer: Monida Montana Health Co-op	$36.10
Rate for Payer: Monida PacificSource	$36.10

URINALYSIS MICRO ONLY

Facility

$36.00

Service Code	HCPCS 81015
Hospital Charge Code	4081015
Hospital Revenue Code	307
Min. Negotiated Rate	$25.20
Max. Negotiated Rate	$36.00
Rate for Payer: Aetna Commercial	$34.20
Rate for Payer: Aetna Medicare	$32.40
Rate for Payer: BCBS MT CHIP	$32.40
Rate for Payer: BCBS MT Closed Plan Network	$34.20
Rate for Payer: BCBS MT HealthLink	$32.40
Rate for Payer: BCBS MT Medicare	$32.40
Rate for Payer: BCBS MT POS	$34.20
Rate for Payer: BCBS MT Traditional	$36.00
Rate for Payer: Cash Price	$32.40
Rate for Payer: Cigna Commercial	$34.20
Rate for Payer: Cigna Medicare	$32.40
Rate for Payer: Medicaid All Medicaid	$33.12
Rate for Payer: Medicare All Medicare	$25.20
Rate for Payer: Monida Allegiance	$34.20
Rate for Payer: Monida First Choice Health	$34.92
Rate for Payer: Monida Montana Health Co-op	$34.20
Rate for Payer: Monida PacificSource	$34.20

URINALYSIS MICRO ONLY

Facility

$36.00

Service Code	HCPCS 81015
Hospital Charge Code	4081015
Hospital Revenue Code	307
Min. Negotiated Rate	$25.20
Max. Negotiated Rate	$36.00
Rate for Payer: Aetna Commercial	$34.20
Rate for Payer: Aetna Medicare	$32.40
Rate for Payer: BCBS MT CHIP	$32.40
Rate for Payer: BCBS MT Closed Plan Network	$34.20
Rate for Payer: BCBS MT HealthLink	$32.40
Rate for Payer: BCBS MT Medicare	$32.40
Rate for Payer: BCBS MT POS	$34.20
Rate for Payer: BCBS MT Traditional	$36.00
Rate for Payer: Cash Price	$32.40
Rate for Payer: Cigna Commercial	$34.20
Rate for Payer: Cigna Medicare	$32.40
Rate for Payer: Medicaid All Medicaid	$33.12
Rate for Payer: Medicare All Medicare	$25.20
Rate for Payer: Monida Allegiance	$34.20
Rate for Payer: Monida First Choice Health	$34.92
Rate for Payer: Monida Montana Health Co-op	$34.20
Rate for Payer: Monida PacificSource	$34.20

URINE CULTURE (008847)

Facility

$18.00

Service Code	HCPCS 87086
Hospital Charge Code	4087086
Hospital Revenue Code	300
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