Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

PROTEIN ELECTRO W/ REFLEX IFE (123100)

Facility

$105.00

Service Code	HCPCS 84165
Hospital Charge Code	4041651
Hospital Revenue Code	300
Min. Negotiated Rate	$73.50
Max. Negotiated Rate	$105.00
Rate for Payer: Aetna Commercial	$99.75
Rate for Payer: Aetna Medicare	$94.50
Rate for Payer: BCBS MT CHIP	$94.50
Rate for Payer: BCBS MT Closed Plan Network	$99.75
Rate for Payer: BCBS MT HealthLink	$94.50
Rate for Payer: BCBS MT Medicare	$94.50
Rate for Payer: BCBS MT POS	$99.75
Rate for Payer: BCBS MT Traditional	$105.00
Rate for Payer: Cash Price	$94.50
Rate for Payer: Cigna Commercial	$99.75
Rate for Payer: Cigna Medicare	$94.50
Rate for Payer: Medicaid All Medicaid	$96.60
Rate for Payer: Medicare All Medicare	$73.50
Rate for Payer: Monida Allegiance	$99.75
Rate for Payer: Monida First Choice Health	$101.85
Rate for Payer: Monida Montana Health Co-op	$99.75
Rate for Payer: Monida PacificSource	$99.75

PROTEIN S ANTIGEN (164517)

Facility

$96.00

Service Code	HCPCS 85306
Hospital Charge Code	4085306
Hospital Revenue Code	301
Min. Negotiated Rate	$67.20
Max. Negotiated Rate	$96.00
Rate for Payer: Aetna Commercial	$91.20
Rate for Payer: Aetna Medicare	$86.40
Rate for Payer: BCBS MT CHIP	$86.40
Rate for Payer: BCBS MT Closed Plan Network	$91.20
Rate for Payer: BCBS MT HealthLink	$86.40
Rate for Payer: BCBS MT Medicare	$86.40
Rate for Payer: BCBS MT POS	$91.20
Rate for Payer: BCBS MT Traditional	$96.00
Rate for Payer: Cash Price	$86.40
Rate for Payer: Cigna Commercial	$91.20
Rate for Payer: Cigna Medicare	$86.40
Rate for Payer: Medicaid All Medicaid	$88.32
Rate for Payer: Medicare All Medicare	$67.20
Rate for Payer: Monida Allegiance	$91.20
Rate for Payer: Monida First Choice Health	$93.12
Rate for Payer: Monida Montana Health Co-op	$91.20
Rate for Payer: Monida PacificSource	$91.20

PROTEIN S ANTIGEN (164517)

Facility

$96.00

Service Code	HCPCS 85306
Hospital Charge Code	4085306
Hospital Revenue Code	301
Min. Negotiated Rate	$67.20
Max. Negotiated Rate	$96.00
Rate for Payer: Aetna Commercial	$91.20
Rate for Payer: Aetna Medicare	$86.40
Rate for Payer: BCBS MT CHIP	$86.40
Rate for Payer: BCBS MT Closed Plan Network	$91.20
Rate for Payer: BCBS MT HealthLink	$86.40
Rate for Payer: BCBS MT Medicare	$86.40
Rate for Payer: BCBS MT POS	$91.20
Rate for Payer: BCBS MT Traditional	$96.00
Rate for Payer: Cash Price	$86.40
Rate for Payer: Cigna Commercial	$91.20
Rate for Payer: Cigna Medicare	$86.40
Rate for Payer: Medicaid All Medicaid	$88.32
Rate for Payer: Medicare All Medicare	$67.20
Rate for Payer: Monida Allegiance	$91.20
Rate for Payer: Monida First Choice Health	$93.12
Rate for Payer: Monida Montana Health Co-op	$91.20
Rate for Payer: Monida PacificSource	$91.20

.PROTEIN S, TOTAL

Facility

$96.00

Service Code	HCPCS 85305
Hospital Charge Code	4085305
Hospital Revenue Code	301
Min. Negotiated Rate	$67.20
Max. Negotiated Rate	$96.00
Rate for Payer: Aetna Commercial	$91.20
Rate for Payer: Aetna Medicare	$86.40
Rate for Payer: BCBS MT CHIP	$86.40
Rate for Payer: BCBS MT Closed Plan Network	$91.20
Rate for Payer: BCBS MT HealthLink	$86.40
Rate for Payer: BCBS MT Medicare	$86.40
Rate for Payer: BCBS MT POS	$91.20
Rate for Payer: BCBS MT Traditional	$96.00
Rate for Payer: Cash Price	$86.40
Rate for Payer: Cigna Commercial	$91.20
Rate for Payer: Cigna Medicare	$86.40
Rate for Payer: Medicaid All Medicaid	$88.32
Rate for Payer: Medicare All Medicare	$67.20
Rate for Payer: Monida Allegiance	$91.20
Rate for Payer: Monida First Choice Health	$93.12
Rate for Payer: Monida Montana Health Co-op	$91.20
Rate for Payer: Monida PacificSource	$91.20

.PROTEIN S, TOTAL

Facility

$96.00

Service Code	HCPCS 85305
Hospital Charge Code	4085305
Hospital Revenue Code	301
Min. Negotiated Rate	$67.20
Max. Negotiated Rate	$96.00
Rate for Payer: Aetna Commercial	$91.20
Rate for Payer: Aetna Medicare	$86.40
Rate for Payer: BCBS MT CHIP	$86.40
Rate for Payer: BCBS MT Closed Plan Network	$91.20
Rate for Payer: BCBS MT HealthLink	$86.40
Rate for Payer: BCBS MT Medicare	$86.40
Rate for Payer: BCBS MT POS	$91.20
Rate for Payer: BCBS MT Traditional	$96.00
Rate for Payer: Cash Price	$86.40
Rate for Payer: Cigna Commercial	$91.20
Rate for Payer: Cigna Medicare	$86.40
Rate for Payer: Medicaid All Medicaid	$88.32
Rate for Payer: Medicare All Medicare	$67.20
Rate for Payer: Monida Allegiance	$91.20
Rate for Payer: Monida First Choice Health	$93.12
Rate for Payer: Monida Montana Health Co-op	$91.20
Rate for Payer: Monida PacificSource	$91.20

PROTEIN, TOTAL

Facility

$50.00

Service Code	HCPCS 84155
Hospital Charge Code	4084155
Hospital Revenue Code	301
Min. Negotiated Rate	$35.00
Max. Negotiated Rate	$50.00
Rate for Payer: Aetna Commercial	$47.50
Rate for Payer: Aetna Medicare	$45.00
Rate for Payer: BCBS MT CHIP	$45.00
Rate for Payer: BCBS MT Closed Plan Network	$47.50
Rate for Payer: BCBS MT HealthLink	$45.00
Rate for Payer: BCBS MT Medicare	$45.00
Rate for Payer: BCBS MT POS	$47.50
Rate for Payer: BCBS MT Traditional	$50.00
Rate for Payer: Cash Price	$45.00
Rate for Payer: Cigna Commercial	$47.50
Rate for Payer: Cigna Medicare	$45.00
Rate for Payer: Medicaid All Medicaid	$46.00
Rate for Payer: Medicare All Medicare	$35.00
Rate for Payer: Monida Allegiance	$47.50
Rate for Payer: Monida First Choice Health	$48.50
Rate for Payer: Monida Montana Health Co-op	$47.50
Rate for Payer: Monida PacificSource	$47.50

PROTEIN, TOTAL

Facility

$50.00

Service Code	HCPCS 84155
Hospital Charge Code	4084155
Hospital Revenue Code	301
Min. Negotiated Rate	$35.00
Max. Negotiated Rate	$50.00
Rate for Payer: Aetna Commercial	$47.50
Rate for Payer: Aetna Medicare	$45.00
Rate for Payer: BCBS MT CHIP	$45.00
Rate for Payer: BCBS MT Closed Plan Network	$47.50
Rate for Payer: BCBS MT HealthLink	$45.00
Rate for Payer: BCBS MT Medicare	$45.00
Rate for Payer: BCBS MT POS	$47.50
Rate for Payer: BCBS MT Traditional	$50.00
Rate for Payer: Cash Price	$45.00
Rate for Payer: Cigna Commercial	$47.50
Rate for Payer: Cigna Medicare	$45.00
Rate for Payer: Medicaid All Medicaid	$46.00
Rate for Payer: Medicare All Medicare	$35.00
Rate for Payer: Monida Allegiance	$47.50
Rate for Payer: Monida First Choice Health	$48.50
Rate for Payer: Monida Montana Health Co-op	$47.50
Rate for Payer: Monida PacificSource	$47.50

PROTEIN, TOTAL, URINE, RANDOM (013664)

Facility

$55.00

Service Code	HCPCS 84156
Hospital Charge Code	4041561
Hospital Revenue Code	300
Min. Negotiated Rate	$38.50
Max. Negotiated Rate	$55.00
Rate for Payer: Aetna Commercial	$52.25
Rate for Payer: Aetna Medicare	$49.50
Rate for Payer: BCBS MT CHIP	$49.50
Rate for Payer: BCBS MT Closed Plan Network	$52.25
Rate for Payer: BCBS MT HealthLink	$49.50
Rate for Payer: BCBS MT Medicare	$49.50
Rate for Payer: BCBS MT POS	$52.25
Rate for Payer: BCBS MT Traditional	$55.00
Rate for Payer: Cash Price	$49.50
Rate for Payer: Cigna Commercial	$52.25
Rate for Payer: Cigna Medicare	$49.50
Rate for Payer: Medicaid All Medicaid	$50.60
Rate for Payer: Medicare All Medicare	$38.50
Rate for Payer: Monida Allegiance	$52.25
Rate for Payer: Monida First Choice Health	$53.35
Rate for Payer: Monida Montana Health Co-op	$52.25
Rate for Payer: Monida PacificSource	$52.25

PROTEIN, TOTAL, URINE, RANDOM (013664)

Facility

$55.00

Service Code	HCPCS 84156
Hospital Charge Code	4041561
Hospital Revenue Code	300
Min. Negotiated Rate	$38.50
Max. Negotiated Rate	$55.00
Rate for Payer: Aetna Commercial	$52.25
Rate for Payer: Aetna Medicare	$49.50
Rate for Payer: BCBS MT CHIP	$49.50
Rate for Payer: BCBS MT Closed Plan Network	$52.25
Rate for Payer: BCBS MT HealthLink	$49.50
Rate for Payer: BCBS MT Medicare	$49.50
Rate for Payer: BCBS MT POS	$52.25
Rate for Payer: BCBS MT Traditional	$55.00
Rate for Payer: Cash Price	$49.50
Rate for Payer: Cigna Commercial	$52.25
Rate for Payer: Cigna Medicare	$49.50
Rate for Payer: Medicaid All Medicaid	$50.60
Rate for Payer: Medicare All Medicare	$38.50
Rate for Payer: Monida Allegiance	$52.25
Rate for Payer: Monida First Choice Health	$53.35
Rate for Payer: Monida Montana Health Co-op	$52.25
Rate for Payer: Monida PacificSource	$52.25

PROTHROMBIN COMPLEX 1000IU (KCENTRA)

Facility

$5,228.00

Service Code	HCPCS J7168
Hospital Charge Code	3007361
Hospital Revenue Code	258
Min. Negotiated Rate	$3,659.60
Max. Negotiated Rate	$5,228.00
Rate for Payer: Aetna Commercial	$4,966.60
Rate for Payer: Aetna Medicare	$4,705.20
Rate for Payer: BCBS MT CHIP	$4,705.20
Rate for Payer: BCBS MT Closed Plan Network	$4,966.60
Rate for Payer: BCBS MT HealthLink	$4,705.20
Rate for Payer: BCBS MT Medicare	$4,705.20
Rate for Payer: BCBS MT POS	$4,966.60
Rate for Payer: BCBS MT Traditional	$5,228.00
Rate for Payer: Cash Price	$4,705.20
Rate for Payer: Cigna Commercial	$4,966.60
Rate for Payer: Cigna Medicare	$4,705.20
Rate for Payer: Medicaid All Medicaid	$4,809.76
Rate for Payer: Medicare All Medicare	$3,659.60
Rate for Payer: Monida Allegiance	$4,966.60
Rate for Payer: Monida First Choice Health	$5,071.16
Rate for Payer: Monida Montana Health Co-op	$4,966.60
Rate for Payer: Monida PacificSource	$4,966.60

PROTHROMBIN COMPLEX 1000IU (KCENTRA)

Facility

$5,228.00

Service Code	HCPCS J7168
Hospital Charge Code	3007361
Hospital Revenue Code	258
Min. Negotiated Rate	$3,659.60
Max. Negotiated Rate	$5,228.00
Rate for Payer: Aetna Commercial	$4,966.60
Rate for Payer: Aetna Medicare	$4,705.20
Rate for Payer: BCBS MT CHIP	$4,705.20
Rate for Payer: BCBS MT Closed Plan Network	$4,966.60
Rate for Payer: BCBS MT HealthLink	$4,705.20
Rate for Payer: BCBS MT Medicare	$4,705.20
Rate for Payer: BCBS MT POS	$4,966.60
Rate for Payer: BCBS MT Traditional	$5,228.00
Rate for Payer: Cash Price	$4,705.20
Rate for Payer: Cigna Commercial	$4,966.60
Rate for Payer: Cigna Medicare	$4,705.20
Rate for Payer: Medicaid All Medicaid	$4,809.76
Rate for Payer: Medicare All Medicare	$3,659.60
Rate for Payer: Monida Allegiance	$4,966.60
Rate for Payer: Monida First Choice Health	$5,071.16
Rate for Payer: Monida Montana Health Co-op	$4,966.60
Rate for Payer: Monida PacificSource	$4,966.60

PROTHROMBIN GENE ANALYSIS (511162)

Facility

$270.00

Service Code	HCPCS 81240
Hospital Charge Code	4081240
Hospital Revenue Code	301
Min. Negotiated Rate	$189.00
Max. Negotiated Rate	$270.00
Rate for Payer: Aetna Commercial	$256.50
Rate for Payer: Aetna Medicare	$243.00
Rate for Payer: BCBS MT CHIP	$243.00
Rate for Payer: BCBS MT Closed Plan Network	$256.50
Rate for Payer: BCBS MT HealthLink	$243.00
Rate for Payer: BCBS MT Medicare	$243.00
Rate for Payer: BCBS MT POS	$256.50
Rate for Payer: BCBS MT Traditional	$270.00
Rate for Payer: Cash Price	$243.00
Rate for Payer: Cigna Commercial	$256.50
Rate for Payer: Cigna Medicare	$243.00
Rate for Payer: Medicaid All Medicaid	$248.40
Rate for Payer: Medicare All Medicare	$189.00
Rate for Payer: Monida Allegiance	$256.50
Rate for Payer: Monida First Choice Health	$261.90
Rate for Payer: Monida Montana Health Co-op	$256.50
Rate for Payer: Monida PacificSource	$256.50

PROTHROMBIN GENE ANALYSIS (511162)

Facility

$270.00

Service Code	HCPCS 81240
Hospital Charge Code	4081240
Hospital Revenue Code	301
Min. Negotiated Rate	$189.00
Max. Negotiated Rate	$270.00
Rate for Payer: Aetna Commercial	$256.50
Rate for Payer: Aetna Medicare	$243.00
Rate for Payer: BCBS MT CHIP	$243.00
Rate for Payer: BCBS MT Closed Plan Network	$256.50
Rate for Payer: BCBS MT HealthLink	$243.00
Rate for Payer: BCBS MT Medicare	$243.00
Rate for Payer: BCBS MT POS	$256.50
Rate for Payer: BCBS MT Traditional	$270.00
Rate for Payer: Cash Price	$243.00
Rate for Payer: Cigna Commercial	$256.50
Rate for Payer: Cigna Medicare	$243.00
Rate for Payer: Medicaid All Medicaid	$248.40
Rate for Payer: Medicare All Medicare	$189.00
Rate for Payer: Monida Allegiance	$256.50
Rate for Payer: Monida First Choice Health	$261.90
Rate for Payer: Monida Montana Health Co-op	$256.50
Rate for Payer: Monida PacificSource	$256.50

PROTHROMBIN TIME (005199)

Facility

$7.00

Service Code	HCPCS 85610
Hospital Charge Code	4000068
Hospital Revenue Code	300
Min. Negotiated Rate	$4.90
Max. Negotiated Rate	$7.00
Rate for Payer: Aetna Commercial	$6.65
Rate for Payer: Aetna Medicare	$6.30
Rate for Payer: BCBS MT CHIP	$6.30
Rate for Payer: BCBS MT Closed Plan Network	$6.65
Rate for Payer: BCBS MT HealthLink	$6.30
Rate for Payer: BCBS MT Medicare	$6.30
Rate for Payer: BCBS MT POS	$6.65
Rate for Payer: BCBS MT Traditional	$7.00
Rate for Payer: Cash Price	$6.30
Rate for Payer: Cigna Commercial	$6.65
Rate for Payer: Cigna Medicare	$6.30
Rate for Payer: Medicaid All Medicaid	$6.44
Rate for Payer: Medicare All Medicare	$4.90
Rate for Payer: Monida Allegiance	$6.65
Rate for Payer: Monida First Choice Health	$6.79
Rate for Payer: Monida Montana Health Co-op	$6.65
Rate for Payer: Monida PacificSource	$6.65

PROTHROMBIN TIME (005199)

Facility

$7.00

Service Code	HCPCS 85610
Hospital Charge Code	4000068
Hospital Revenue Code	300
Min. Negotiated Rate	$4.90
Max. Negotiated Rate	$7.00
Rate for Payer: Aetna Commercial	$6.65
Rate for Payer: Aetna Medicare	$6.30
Rate for Payer: BCBS MT CHIP	$6.30
Rate for Payer: BCBS MT Closed Plan Network	$6.65
Rate for Payer: BCBS MT HealthLink	$6.30
Rate for Payer: BCBS MT Medicare	$6.30
Rate for Payer: BCBS MT POS	$6.65
Rate for Payer: BCBS MT Traditional	$7.00
Rate for Payer: Cash Price	$6.30
Rate for Payer: Cigna Commercial	$6.65
Rate for Payer: Cigna Medicare	$6.30
Rate for Payer: Medicaid All Medicaid	$6.44
Rate for Payer: Medicare All Medicare	$4.90
Rate for Payer: Monida Allegiance	$6.65
Rate for Payer: Monida First Choice Health	$6.79
Rate for Payer: Monida Montana Health Co-op	$6.65
Rate for Payer: Monida PacificSource	$6.65

PROTIME/INR

Facility

$67.00

Service Code	HCPCS 85610
Hospital Charge Code	4085610
Hospital Revenue Code	300
Min. Negotiated Rate	$46.90
Max. Negotiated Rate	$67.00
Rate for Payer: Aetna Commercial	$63.65
Rate for Payer: Aetna Medicare	$60.30
Rate for Payer: BCBS MT CHIP	$60.30
Rate for Payer: BCBS MT Closed Plan Network	$63.65
Rate for Payer: BCBS MT HealthLink	$60.30
Rate for Payer: BCBS MT Medicare	$60.30
Rate for Payer: BCBS MT POS	$63.65
Rate for Payer: BCBS MT Traditional	$67.00
Rate for Payer: Cash Price	$60.30
Rate for Payer: Cigna Commercial	$63.65
Rate for Payer: Cigna Medicare	$60.30
Rate for Payer: Medicaid All Medicaid	$61.64
Rate for Payer: Medicare All Medicare	$46.90
Rate for Payer: Monida Allegiance	$63.65
Rate for Payer: Monida First Choice Health	$64.99
Rate for Payer: Monida Montana Health Co-op	$63.65
Rate for Payer: Monida PacificSource	$63.65

PROTIME/INR

Facility

$67.00

Service Code	HCPCS 85610
Hospital Charge Code	4085610
Hospital Revenue Code	300
Min. Negotiated Rate	$46.90
Max. Negotiated Rate	$67.00
Rate for Payer: Aetna Commercial	$63.65
Rate for Payer: Aetna Medicare	$60.30
Rate for Payer: BCBS MT CHIP	$60.30
Rate for Payer: BCBS MT Closed Plan Network	$63.65
Rate for Payer: BCBS MT HealthLink	$60.30
Rate for Payer: BCBS MT Medicare	$60.30
Rate for Payer: BCBS MT POS	$63.65
Rate for Payer: BCBS MT Traditional	$67.00
Rate for Payer: Cash Price	$60.30
Rate for Payer: Cigna Commercial	$63.65
Rate for Payer: Cigna Medicare	$60.30
Rate for Payer: Medicaid All Medicaid	$61.64
Rate for Payer: Medicare All Medicare	$46.90
Rate for Payer: Monida Allegiance	$63.65
Rate for Payer: Monida First Choice Health	$64.99
Rate for Payer: Monida Montana Health Co-op	$63.65
Rate for Payer: Monida PacificSource	$63.65

PRO US DOP ECHOCARD PULS WVEE W/SPE F-UP

Professional

Both

$27.00

Service Code	HCPCS 93321 26
Hospital Charge Code	50002388
Hospital Revenue Code	972
Min. Negotiated Rate	$18.90
Max. Negotiated Rate	$26.19
Rate for Payer: Aetna Commercial	$25.65
Rate for Payer: Aetna Medicare	$24.30
Rate for Payer: Cash Price	$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

.PSA FREE (480772)

Facility

$32.00

Service Code	HCPCS 84154
Hospital Charge Code	4084154
Hospital Revenue Code	301
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

.PSA FREE (480772)

Facility

$32.00

Service Code	HCPCS 84154
Hospital Charge Code	4084154
Hospital Revenue Code	301
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

PSA TOTAL W/ REFLEX TO PSA FREE (480772)

Facility

$77.00

Service Code	HCPCS 84153
Hospital Charge Code	4041531
Hospital Revenue Code	301
Min. Negotiated Rate	$53.90
Max. Negotiated Rate	$77.00
Rate for Payer: Aetna Commercial	$73.15
Rate for Payer: Aetna Medicare	$69.30
Rate for Payer: BCBS MT CHIP	$69.30
Rate for Payer: BCBS MT Closed Plan Network	$73.15
Rate for Payer: BCBS MT HealthLink	$69.30
Rate for Payer: BCBS MT Medicare	$69.30
Rate for Payer: BCBS MT POS	$73.15
Rate for Payer: BCBS MT Traditional	$77.00
Rate for Payer: Cash Price	$69.30
Rate for Payer: Cigna Commercial	$73.15
Rate for Payer: Cigna Medicare	$69.30
Rate for Payer: Medicaid All Medicaid	$70.84
Rate for Payer: Medicare All Medicare	$53.90
Rate for Payer: Monida Allegiance	$73.15
Rate for Payer: Monida First Choice Health	$74.69
Rate for Payer: Monida Montana Health Co-op	$73.15
Rate for Payer: Monida PacificSource	$73.15

PSA TOTAL W/ REFLEX TO PSA FREE (480772)

Facility

$77.00

Service Code	HCPCS 84153
Hospital Charge Code	4041531
Hospital Revenue Code	301
Min. Negotiated Rate	$53.90
Max. Negotiated Rate	$77.00
Rate for Payer: Aetna Commercial	$73.15
Rate for Payer: Aetna Medicare	$69.30
Rate for Payer: BCBS MT CHIP	$69.30
Rate for Payer: BCBS MT Closed Plan Network	$73.15
Rate for Payer: BCBS MT HealthLink	$69.30
Rate for Payer: BCBS MT Medicare	$69.30
Rate for Payer: BCBS MT POS	$73.15
Rate for Payer: BCBS MT Traditional	$77.00
Rate for Payer: Cash Price	$69.30
Rate for Payer: Cigna Commercial	$73.15
Rate for Payer: Cigna Medicare	$69.30
Rate for Payer: Medicaid All Medicaid	$70.84
Rate for Payer: Medicare All Medicare	$53.90
Rate for Payer: Monida Allegiance	$73.15
Rate for Payer: Monida First Choice Health	$74.69
Rate for Payer: Monida Montana Health Co-op	$73.15
Rate for Payer: Monida PacificSource	$73.15

PSA ULTRASENSITIVE

Facility

$78.54

Service Code	HCPCS 84153
Hospital Charge Code	4087959
Hospital Revenue Code	302
Min. Negotiated Rate	$54.98
Max. Negotiated Rate	$78.54
Rate for Payer: Aetna Commercial	$74.61
Rate for Payer: Aetna Medicare	$70.69
Rate for Payer: BCBS MT CHIP	$70.69
Rate for Payer: BCBS MT Closed Plan Network	$74.61
Rate for Payer: BCBS MT HealthLink	$70.69
Rate for Payer: BCBS MT Medicare	$70.69
Rate for Payer: BCBS MT POS	$74.61
Rate for Payer: BCBS MT Traditional	$78.54
Rate for Payer: Cash Price	$70.69
Rate for Payer: Cigna Commercial	$74.61
Rate for Payer: Cigna Medicare	$70.69
Rate for Payer: Medicaid All Medicaid	$72.26
Rate for Payer: Medicare All Medicare	$54.98
Rate for Payer: Monida Allegiance	$74.61
Rate for Payer: Monida First Choice Health	$76.18
Rate for Payer: Monida Montana Health Co-op	$74.61
Rate for Payer: Monida PacificSource	$74.61

PSA ULTRASENSITIVE

Facility

$78.54

Service Code	HCPCS 84153
Hospital Charge Code	4087959
Hospital Revenue Code	302
Min. Negotiated Rate	$54.98
Max. Negotiated Rate	$78.54
Rate for Payer: Aetna Commercial	$74.61
Rate for Payer: Aetna Medicare	$70.69
Rate for Payer: BCBS MT CHIP	$70.69
Rate for Payer: BCBS MT Closed Plan Network	$74.61
Rate for Payer: BCBS MT HealthLink	$70.69
Rate for Payer: BCBS MT Medicare	$70.69
Rate for Payer: BCBS MT POS	$74.61
Rate for Payer: BCBS MT Traditional	$78.54
Rate for Payer: Cash Price	$70.69
Rate for Payer: Cigna Commercial	$74.61
Rate for Payer: Cigna Medicare	$70.69
Rate for Payer: Medicaid All Medicaid	$72.26
Rate for Payer: Medicare All Medicare	$54.98
Rate for Payer: Monida Allegiance	$74.61
Rate for Payer: Monida First Choice Health	$76.18
Rate for Payer: Monida Montana Health Co-op	$74.61
Rate for Payer: Monida PacificSource	$74.61

PSYCHOTHERAPY CRISIS +30 MIN

Facility

$156.00

Service Code	HCPCS 90840
Hospital Charge Code	8190840
Hospital Revenue Code	900
Min. Negotiated Rate	$109.20
Max. Negotiated Rate	$156.00
Rate for Payer: Aetna Commercial	$148.20
Rate for Payer: Aetna Medicare	$140.40
Rate for Payer: BCBS MT CHIP	$140.40
Rate for Payer: BCBS MT Closed Plan Network	$148.20
Rate for Payer: BCBS MT HealthLink	$140.40
Rate for Payer: BCBS MT Medicare	$140.40
Rate for Payer: BCBS MT POS	$148.20
Rate for Payer: BCBS MT Traditional	$156.00
Rate for Payer: Cash Price	$140.40
Rate for Payer: Cigna Commercial	$148.20
Rate for Payer: Cigna Medicare	$140.40
Rate for Payer: Medicaid All Medicaid	$143.52
Rate for Payer: Medicare All Medicare	$109.20
Rate for Payer: Monida Allegiance	$148.20
Rate for Payer: Monida First Choice Health	$151.32
Rate for Payer: Monida Montana Health Co-op	$148.20
Rate for Payer: Monida PacificSource	$148.20

Know your out-of-pocket cost for care.

All Charges