Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

PROBIOTIC TABLET

Facility

$8.00

Service Code	HCPCS A9150
Hospital Charge Code	3000008
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

PROCALCITONIN (164750)

Facility

$561.00

Service Code	CPT 84145
Hospital Charge Code	4084145
Hospital Revenue Code	300
Min. Negotiated Rate	$392.70
Max. Negotiated Rate	$561.00
Rate for Payer: Aetna Commercial	$532.95
Rate for Payer: Aetna Medicare	$504.90
Rate for Payer: BCBS MT CHIP	$504.90
Rate for Payer: BCBS MT Closed Plan Network	$532.95
Rate for Payer: BCBS MT HealthLink	$504.90
Rate for Payer: BCBS MT Medicare	$504.90
Rate for Payer: BCBS MT POS	$532.95
Rate for Payer: BCBS MT Traditional	$561.00
Rate for Payer: Cash Price	$504.90
Rate for Payer: Cigna Commercial	$532.95
Rate for Payer: Cigna Medicare	$504.90
Rate for Payer: Medicaid All Medicaid	$516.12
Rate for Payer: Medicare All Medicare	$392.70
Rate for Payer: Monida Allegiance	$532.95
Rate for Payer: Monida First Choice Health	$544.17
Rate for Payer: Monida Montana Health Co-op	$532.95
Rate for Payer: Monida PacificSource	$532.95

PROCALCITONIN (164750)

Facility

$561.00

Service Code	CPT 84145
Hospital Charge Code	4084145
Hospital Revenue Code	300
Min. Negotiated Rate	$392.70
Max. Negotiated Rate	$561.00
Rate for Payer: Aetna Commercial	$532.95
Rate for Payer: Aetna Medicare	$504.90
Rate for Payer: BCBS MT CHIP	$504.90
Rate for Payer: BCBS MT Closed Plan Network	$532.95
Rate for Payer: BCBS MT HealthLink	$504.90
Rate for Payer: BCBS MT Medicare	$504.90
Rate for Payer: BCBS MT POS	$532.95
Rate for Payer: BCBS MT Traditional	$561.00
Rate for Payer: Cash Price	$504.90
Rate for Payer: Cigna Commercial	$532.95
Rate for Payer: Cigna Medicare	$504.90
Rate for Payer: Medicaid All Medicaid	$516.12
Rate for Payer: Medicare All Medicare	$392.70
Rate for Payer: Monida Allegiance	$532.95
Rate for Payer: Monida First Choice Health	$544.17
Rate for Payer: Monida Montana Health Co-op	$532.95
Rate for Payer: Monida PacificSource	$532.95

PROCALCITONIN ASSAY

Facility

$4,306.18

Hospital Charge Code	90197091
Hospital Revenue Code	270
Min. Negotiated Rate	$3,014.33
Max. Negotiated Rate	$4,306.18
Rate for Payer: Aetna Commercial	$4,090.87
Rate for Payer: Aetna Medicare	$3,875.56
Rate for Payer: BCBS MT CHIP	$3,875.56
Rate for Payer: BCBS MT Closed Plan Network	$4,090.87
Rate for Payer: BCBS MT HealthLink	$3,875.56
Rate for Payer: BCBS MT Medicare	$3,875.56
Rate for Payer: BCBS MT POS	$4,090.87
Rate for Payer: BCBS MT Traditional	$4,306.18
Rate for Payer: Cash Price	$3,875.56
Rate for Payer: Cigna Commercial	$4,090.87
Rate for Payer: Cigna Medicare	$3,875.56
Rate for Payer: Medicaid All Medicaid	$3,961.69
Rate for Payer: Medicare All Medicare	$3,014.33
Rate for Payer: Monida Allegiance	$4,090.87
Rate for Payer: Monida First Choice Health	$4,176.99
Rate for Payer: Monida Montana Health Co-op	$4,090.87
Rate for Payer: Monida PacificSource	$4,090.87

PROCALCITONIN ASSAY

Facility

$4,306.18

Hospital Charge Code	90197091
Hospital Revenue Code	270
Min. Negotiated Rate	$3,014.33
Max. Negotiated Rate	$4,306.18
Rate for Payer: Aetna Commercial	$4,090.87
Rate for Payer: Aetna Medicare	$3,875.56
Rate for Payer: BCBS MT CHIP	$3,875.56
Rate for Payer: BCBS MT Closed Plan Network	$4,090.87
Rate for Payer: BCBS MT HealthLink	$3,875.56
Rate for Payer: BCBS MT Medicare	$3,875.56
Rate for Payer: BCBS MT POS	$4,090.87
Rate for Payer: BCBS MT Traditional	$4,306.18
Rate for Payer: Cash Price	$3,875.56
Rate for Payer: Cigna Commercial	$4,090.87
Rate for Payer: Cigna Medicare	$3,875.56
Rate for Payer: Medicaid All Medicaid	$3,961.69
Rate for Payer: Medicare All Medicare	$3,014.33
Rate for Payer: Monida Allegiance	$4,090.87
Rate for Payer: Monida First Choice Health	$4,176.99
Rate for Payer: Monida Montana Health Co-op	$4,090.87
Rate for Payer: Monida PacificSource	$4,090.87

PROCALCITONIN RVMC

Facility

$256.00

Service Code	CPT 84145
Hospital Charge Code	4087916
Hospital Revenue Code	301
Min. Negotiated Rate	$179.20
Max. Negotiated Rate	$256.00
Rate for Payer: Aetna Commercial	$243.20
Rate for Payer: Aetna Medicare	$230.40
Rate for Payer: BCBS MT CHIP	$230.40
Rate for Payer: BCBS MT Closed Plan Network	$243.20
Rate for Payer: BCBS MT HealthLink	$230.40
Rate for Payer: BCBS MT Medicare	$230.40
Rate for Payer: BCBS MT POS	$243.20
Rate for Payer: BCBS MT Traditional	$256.00
Rate for Payer: Cash Price	$230.40
Rate for Payer: Cigna Commercial	$243.20
Rate for Payer: Cigna Medicare	$230.40
Rate for Payer: Medicaid All Medicaid	$235.52
Rate for Payer: Medicare All Medicare	$179.20
Rate for Payer: Monida Allegiance	$243.20
Rate for Payer: Monida First Choice Health	$248.32
Rate for Payer: Monida Montana Health Co-op	$243.20
Rate for Payer: Monida PacificSource	$243.20

PROCALCITONIN RVMC

Facility

$256.00

Service Code	CPT 84145
Hospital Charge Code	4087916
Hospital Revenue Code	301
Min. Negotiated Rate	$179.20
Max. Negotiated Rate	$256.00
Rate for Payer: Aetna Commercial	$243.20
Rate for Payer: Aetna Medicare	$230.40
Rate for Payer: BCBS MT CHIP	$230.40
Rate for Payer: BCBS MT Closed Plan Network	$243.20
Rate for Payer: BCBS MT HealthLink	$230.40
Rate for Payer: BCBS MT Medicare	$230.40
Rate for Payer: BCBS MT POS	$243.20
Rate for Payer: BCBS MT Traditional	$256.00
Rate for Payer: Cash Price	$230.40
Rate for Payer: Cigna Commercial	$243.20
Rate for Payer: Cigna Medicare	$230.40
Rate for Payer: Medicaid All Medicaid	$235.52
Rate for Payer: Medicare All Medicare	$179.20
Rate for Payer: Monida Allegiance	$243.20
Rate for Payer: Monida First Choice Health	$248.32
Rate for Payer: Monida Montana Health Co-op	$243.20
Rate for Payer: Monida PacificSource	$243.20

PROCHLORPERAZINE INJ [10 MG/2 ML] VIAL

Facility

$21.00

Service Code	HCPCS J0780
Hospital Charge Code	3000403
Hospital Revenue Code	250
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

PROCHLORPERAZINE INJ [10 MG/2 ML] VIAL

Facility

$21.00

Service Code	HCPCS J0780
Hospital Charge Code	3000403
Hospital Revenue Code	250
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

PROCHLORPERAZINE TAB [10 MG] NF

Facility

$8.00

Service Code	HCPCS J8499
Hospital Charge Code	3000620
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

PROCHLORPERAZINE TAB [10 MG] NF

Facility

$8.00

Service Code	HCPCS J8499
Hospital Charge Code	3000620
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

PROCHLORPERAZINE TAB [5 MG]

Facility

$8.00

Service Code	HCPCS J8499
Hospital Charge Code	3000404
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

PROCHLORPERAZINE TAB [5 MG]

Facility

$8.00

Service Code	HCPCS J8499
Hospital Charge Code	3000404
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

PROCOLLAGEN TYPE INTACT N TERM PEPTIDE

Facility

$230.00

Service Code	CPT 83519
Hospital Charge Code	4088103
Hospital Revenue Code	302
Min. Negotiated Rate	$161.00
Max. Negotiated Rate	$230.00
Rate for Payer: Aetna Commercial	$218.50
Rate for Payer: Aetna Medicare	$207.00
Rate for Payer: BCBS MT CHIP	$207.00
Rate for Payer: BCBS MT Closed Plan Network	$218.50
Rate for Payer: BCBS MT HealthLink	$207.00
Rate for Payer: BCBS MT Medicare	$207.00
Rate for Payer: BCBS MT POS	$218.50
Rate for Payer: BCBS MT Traditional	$230.00
Rate for Payer: Cash Price	$207.00
Rate for Payer: Cigna Commercial	$218.50
Rate for Payer: Cigna Medicare	$207.00
Rate for Payer: Medicaid All Medicaid	$211.60
Rate for Payer: Medicare All Medicare	$161.00
Rate for Payer: Monida Allegiance	$218.50
Rate for Payer: Monida First Choice Health	$223.10
Rate for Payer: Monida Montana Health Co-op	$218.50
Rate for Payer: Monida PacificSource	$218.50

PROCOLLAGEN TYPE INTACT N TERM PEPTIDE

Facility

$230.00

Service Code	CPT 83519
Hospital Charge Code	4088103
Hospital Revenue Code	302
Min. Negotiated Rate	$161.00
Max. Negotiated Rate	$230.00
Rate for Payer: Aetna Commercial	$218.50
Rate for Payer: Aetna Medicare	$207.00
Rate for Payer: BCBS MT CHIP	$207.00
Rate for Payer: BCBS MT Closed Plan Network	$218.50
Rate for Payer: BCBS MT HealthLink	$207.00
Rate for Payer: BCBS MT Medicare	$207.00
Rate for Payer: BCBS MT POS	$218.50
Rate for Payer: BCBS MT Traditional	$230.00
Rate for Payer: Cash Price	$207.00
Rate for Payer: Cigna Commercial	$218.50
Rate for Payer: Cigna Medicare	$207.00
Rate for Payer: Medicaid All Medicaid	$211.60
Rate for Payer: Medicare All Medicare	$161.00
Rate for Payer: Monida Allegiance	$218.50
Rate for Payer: Monida First Choice Health	$223.10
Rate for Payer: Monida Montana Health Co-op	$218.50
Rate for Payer: Monida PacificSource	$218.50

PROFEE ANESTHESIA COLONOSCOPY 00811

Professional

Both

$525.00

Service Code	CPT 811
Hospital Charge Code	5840006
Hospital Revenue Code	964
Min. Negotiated Rate	$367.50
Max. Negotiated Rate	$525.00
Rate for Payer: Aetna Commercial	$498.75
Rate for Payer: Aetna Medicare	$472.50
Rate for Payer: BCBS MT CHIP	$472.50
Rate for Payer: BCBS MT Closed Plan Network	$498.75
Rate for Payer: BCBS MT HealthLink	$472.50
Rate for Payer: BCBS MT Medicare	$472.50
Rate for Payer: BCBS MT POS	$498.75
Rate for Payer: BCBS MT Traditional	$525.00
Rate for Payer: Cash Price	$472.50
Rate for Payer: Cigna Commercial	$498.75
Rate for Payer: Cigna Medicare	$472.50
Rate for Payer: Medicaid All Medicaid	$483.00
Rate for Payer: Medicare All Medicare	$367.50
Rate for Payer: Monida Allegiance	$498.75
Rate for Payer: Monida First Choice Health	$509.25
Rate for Payer: Monida Montana Health Co-op	$498.75
Rate for Payer: Monida PacificSource	$498.75

PROFEE ANESTHESIA COLONOSCOPY 00812

Professional

Both

$525.00

Service Code	CPT 812
Hospital Charge Code	5840004
Hospital Revenue Code	964
Min. Negotiated Rate	$367.50
Max. Negotiated Rate	$525.00
Rate for Payer: Aetna Commercial	$498.75
Rate for Payer: Aetna Medicare	$472.50
Rate for Payer: BCBS MT CHIP	$472.50
Rate for Payer: BCBS MT Closed Plan Network	$498.75
Rate for Payer: BCBS MT HealthLink	$472.50
Rate for Payer: BCBS MT Medicare	$472.50
Rate for Payer: BCBS MT POS	$498.75
Rate for Payer: BCBS MT Traditional	$525.00
Rate for Payer: Cash Price	$472.50
Rate for Payer: Cigna Commercial	$498.75
Rate for Payer: Cigna Medicare	$472.50
Rate for Payer: Medicaid All Medicaid	$483.00
Rate for Payer: Medicare All Medicare	$367.50
Rate for Payer: Monida Allegiance	$498.75
Rate for Payer: Monida First Choice Health	$509.25
Rate for Payer: Monida Montana Health Co-op	$498.75
Rate for Payer: Monida PacificSource	$498.75

PROFEE ANESTHESIA EGD & COLON 00813

Professional

Both

$675.00

Service Code	CPT 813
Hospital Charge Code	5840007
Hospital Revenue Code	964
Min. Negotiated Rate	$472.50
Max. Negotiated Rate	$675.00
Rate for Payer: Aetna Commercial	$641.25
Rate for Payer: Aetna Medicare	$607.50
Rate for Payer: BCBS MT CHIP	$607.50
Rate for Payer: BCBS MT Closed Plan Network	$641.25
Rate for Payer: BCBS MT HealthLink	$607.50
Rate for Payer: BCBS MT Medicare	$607.50
Rate for Payer: BCBS MT POS	$641.25
Rate for Payer: BCBS MT Traditional	$675.00
Rate for Payer: Cash Price	$607.50
Rate for Payer: Cigna Commercial	$641.25
Rate for Payer: Cigna Medicare	$607.50
Rate for Payer: Medicaid All Medicaid	$621.00
Rate for Payer: Medicare All Medicare	$472.50
Rate for Payer: Monida Allegiance	$641.25
Rate for Payer: Monida First Choice Health	$654.75
Rate for Payer: Monida Montana Health Co-op	$641.25
Rate for Payer: Monida PacificSource	$641.25

PROFEE ANESTHESIA ENDO 00731

Professional

Both

$375.00

Service Code	CPT 731
Hospital Charge Code	5800731
Hospital Revenue Code	964
Min. Negotiated Rate	$262.50
Max. Negotiated Rate	$375.00
Rate for Payer: Aetna Commercial	$356.25
Rate for Payer: Aetna Medicare	$337.50
Rate for Payer: BCBS MT CHIP	$337.50
Rate for Payer: BCBS MT Closed Plan Network	$356.25
Rate for Payer: BCBS MT HealthLink	$337.50
Rate for Payer: BCBS MT Medicare	$337.50
Rate for Payer: BCBS MT POS	$356.25
Rate for Payer: BCBS MT Traditional	$375.00
Rate for Payer: Cash Price	$337.50
Rate for Payer: Cigna Commercial	$356.25
Rate for Payer: Cigna Medicare	$337.50
Rate for Payer: Medicaid All Medicaid	$345.00
Rate for Payer: Medicare All Medicare	$262.50
Rate for Payer: Monida Allegiance	$356.25
Rate for Payer: Monida First Choice Health	$363.75
Rate for Payer: Monida Montana Health Co-op	$356.25
Rate for Payer: Monida PacificSource	$356.25

PRO FEE APPLICATION OF FINGER SPLINT

Professional

Both

$150.00

Service Code	CPT 29130
Hospital Charge Code	7229130
Hospital Revenue Code	981
Min. Negotiated Rate	$105.00
Max. Negotiated Rate	$150.00
Rate for Payer: Aetna Commercial	$142.50
Rate for Payer: Aetna Medicare	$135.00
Rate for Payer: BCBS MT CHIP	$135.00
Rate for Payer: BCBS MT Closed Plan Network	$142.50
Rate for Payer: BCBS MT HealthLink	$135.00
Rate for Payer: BCBS MT Medicare	$135.00
Rate for Payer: BCBS MT POS	$142.50
Rate for Payer: BCBS MT Traditional	$150.00
Rate for Payer: Cash Price	$135.00
Rate for Payer: Cigna Commercial	$142.50
Rate for Payer: Cigna Medicare	$135.00
Rate for Payer: Medicaid All Medicaid	$138.00
Rate for Payer: Medicare All Medicare	$105.00
Rate for Payer: Monida Allegiance	$142.50
Rate for Payer: Monida First Choice Health	$145.50
Rate for Payer: Monida Montana Health Co-op	$142.50
Rate for Payer: Monida PacificSource	$142.50

PRO FEE CLSDTX IPJNT W/MAN W/O ANES26770

Professional

Both

$1,448.00

Service Code	CPT 26770
Hospital Charge Code	726770
Hospital Revenue Code	981
Min. Negotiated Rate	$1,013.60
Max. Negotiated Rate	$1,448.00
Rate for Payer: Aetna Commercial	$1,375.60
Rate for Payer: Aetna Medicare	$1,303.20
Rate for Payer: BCBS MT CHIP	$1,303.20
Rate for Payer: BCBS MT Closed Plan Network	$1,375.60
Rate for Payer: BCBS MT HealthLink	$1,303.20
Rate for Payer: BCBS MT Medicare	$1,303.20
Rate for Payer: BCBS MT POS	$1,375.60
Rate for Payer: BCBS MT Traditional	$1,448.00
Rate for Payer: Cash Price	$1,303.20
Rate for Payer: Cigna Commercial	$1,375.60
Rate for Payer: Cigna Medicare	$1,303.20
Rate for Payer: Medicaid All Medicaid	$1,332.16
Rate for Payer: Medicare All Medicare	$1,013.60
Rate for Payer: Monida Allegiance	$1,375.60
Rate for Payer: Monida First Choice Health	$1,404.56
Rate for Payer: Monida Montana Health Co-op	$1,375.60
Rate for Payer: Monida PacificSource	$1,375.60

PRO FEE CMPLX RPR E/N/E/L 1.1-2.5 CM

Professional

Both

$529.00

Service Code	CPT 13151
Hospital Charge Code	7113151
Hospital Revenue Code	981
Min. Negotiated Rate	$370.30
Max. Negotiated Rate	$529.00
Rate for Payer: Aetna Commercial	$502.55
Rate for Payer: Aetna Medicare	$476.10
Rate for Payer: BCBS MT CHIP	$476.10
Rate for Payer: BCBS MT Closed Plan Network	$502.55
Rate for Payer: BCBS MT HealthLink	$476.10
Rate for Payer: BCBS MT Medicare	$476.10
Rate for Payer: BCBS MT POS	$502.55
Rate for Payer: BCBS MT Traditional	$529.00
Rate for Payer: Cash Price	$476.10
Rate for Payer: Cigna Commercial	$502.55
Rate for Payer: Cigna Medicare	$476.10
Rate for Payer: Medicaid All Medicaid	$486.68
Rate for Payer: Medicare All Medicare	$370.30
Rate for Payer: Monida Allegiance	$502.55
Rate for Payer: Monida First Choice Health	$513.13
Rate for Payer: Monida Montana Health Co-op	$502.55
Rate for Payer: Monida PacificSource	$502.55

PROFEE COLNOSCPY SCRN-NOT HGH RISK G0121

Professional

Both

$304.00

Service Code	HCPCS G0121
Hospital Charge Code	5840121
Hospital Revenue Code	960
Min. Negotiated Rate	$212.80
Max. Negotiated Rate	$294.88
Rate for Payer: Aetna Commercial	$288.80
Rate for Payer: Aetna Medicare	$273.60
Rate for Payer: Cash Price	$273.60
Rate for Payer: Medicaid All Medicaid	$279.68
Rate for Payer: Medicare All Medicare	$212.80
Rate for Payer: Monida Allegiance	$288.80
Rate for Payer: Monida First Choice Health	$294.88
Rate for Payer: Monida Montana Health Co-op	$288.80
Rate for Payer: Monida PacificSource	$288.80

PROFEE COLNOSCPY SCRN-PT HIGH RISK G0105

Professional

Both

$303.00

Service Code	HCPCS G0105
Hospital Charge Code	5840105
Hospital Revenue Code	960
Min. Negotiated Rate	$212.10
Max. Negotiated Rate	$293.91
Rate for Payer: Aetna Commercial	$287.85
Rate for Payer: Aetna Medicare	$272.70
Rate for Payer: Cash Price	$272.70
Rate for Payer: Medicaid All Medicaid	$278.76
Rate for Payer: Medicare All Medicare	$212.10
Rate for Payer: Monida Allegiance	$287.85
Rate for Payer: Monida First Choice Health	$293.91
Rate for Payer: Monida Montana Health Co-op	$287.85
Rate for Payer: Monida PacificSource	$287.85

PROFEE COLONOSCOPY 45378

Professional

Both

$304.00

Service Code	CPT 45378
Hospital Charge Code	5840002
Hospital Revenue Code	960
Min. Negotiated Rate	$212.80
Max. Negotiated Rate	$294.88
Rate for Payer: Aetna Commercial	$288.80
Rate for Payer: Aetna Medicare	$273.60
Rate for Payer: Cash Price	$273.60
Rate for Payer: Medicaid All Medicaid	$279.68
Rate for Payer: Medicare All Medicare	$212.80
Rate for Payer: Monida Allegiance	$288.80
Rate for Payer: Monida First Choice Health	$294.88
Rate for Payer: Monida Montana Health Co-op	$288.80
Rate for Payer: Monida PacificSource	$288.80

Know your out-of-pocket cost for care.

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