Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

TR INCISION AND DRAINAGE ABCESS SIMPLE

Facility

$441.00

Service Code	HCPCS 10060
Hospital Charge Code	1010060
Hospital Revenue Code	761
Min. Negotiated Rate	$308.70
Max. Negotiated Rate	$441.00
Rate for Payer: Aetna Commercial	$418.95
Rate for Payer: Aetna Medicare	$396.90
Rate for Payer: BCBS MT CHIP	$396.90
Rate for Payer: BCBS MT Closed Plan Network	$418.95
Rate for Payer: BCBS MT HealthLink	$396.90
Rate for Payer: BCBS MT Medicare	$396.90
Rate for Payer: BCBS MT POS	$418.95
Rate for Payer: BCBS MT Traditional	$441.00
Rate for Payer: Cash Price	$396.90
Rate for Payer: Cigna Commercial	$418.95
Rate for Payer: Cigna Medicare	$396.90
Rate for Payer: Medicaid All Medicaid	$405.72
Rate for Payer: Medicare All Medicare	$308.70
Rate for Payer: Monida Allegiance	$418.95
Rate for Payer: Monida First Choice Health	$427.77
Rate for Payer: Monida Montana Health Co-op	$418.95
Rate for Payer: Monida PacificSource	$418.95

TR INJ TENDON SHEATH/LIGAMENT

Facility

$331.00

Service Code	HCPCS 20550
Hospital Charge Code	1020550
Hospital Revenue Code	761
Min. Negotiated Rate	$231.70
Max. Negotiated Rate	$331.00
Rate for Payer: Aetna Commercial	$314.45
Rate for Payer: Aetna Medicare	$297.90
Rate for Payer: BCBS MT CHIP	$297.90
Rate for Payer: BCBS MT Closed Plan Network	$314.45
Rate for Payer: BCBS MT HealthLink	$297.90
Rate for Payer: BCBS MT Medicare	$297.90
Rate for Payer: BCBS MT POS	$314.45
Rate for Payer: BCBS MT Traditional	$331.00
Rate for Payer: Cash Price	$297.90
Rate for Payer: Cigna Commercial	$314.45
Rate for Payer: Cigna Medicare	$297.90
Rate for Payer: Medicaid All Medicaid	$304.52
Rate for Payer: Medicare All Medicare	$231.70
Rate for Payer: Monida Allegiance	$314.45
Rate for Payer: Monida First Choice Health	$321.07
Rate for Payer: Monida Montana Health Co-op	$314.45
Rate for Payer: Monida PacificSource	$314.45

TR INJ TENDON SHEATH/LIGAMENT

Facility

$331.00

Service Code	HCPCS 20550
Hospital Charge Code	1020550
Hospital Revenue Code	761
Min. Negotiated Rate	$231.70
Max. Negotiated Rate	$331.00
Rate for Payer: Aetna Commercial	$314.45
Rate for Payer: Aetna Medicare	$297.90
Rate for Payer: BCBS MT CHIP	$297.90
Rate for Payer: BCBS MT Closed Plan Network	$314.45
Rate for Payer: BCBS MT HealthLink	$297.90
Rate for Payer: BCBS MT Medicare	$297.90
Rate for Payer: BCBS MT POS	$314.45
Rate for Payer: BCBS MT Traditional	$331.00
Rate for Payer: Cash Price	$297.90
Rate for Payer: Cigna Commercial	$314.45
Rate for Payer: Cigna Medicare	$297.90
Rate for Payer: Medicaid All Medicaid	$304.52
Rate for Payer: Medicare All Medicare	$231.70
Rate for Payer: Monida Allegiance	$314.45
Rate for Payer: Monida First Choice Health	$321.07
Rate for Payer: Monida Montana Health Co-op	$314.45
Rate for Payer: Monida PacificSource	$314.45

TR: IRRIGATION OF BLADDER

Facility

$154.00

Service Code	HCPCS 51700
Hospital Charge Code	551700
Hospital Revenue Code	761
Min. Negotiated Rate	$107.80
Max. Negotiated Rate	$154.00
Rate for Payer: Aetna Commercial	$146.30
Rate for Payer: Aetna Medicare	$138.60
Rate for Payer: BCBS MT CHIP	$138.60
Rate for Payer: BCBS MT Closed Plan Network	$146.30
Rate for Payer: BCBS MT HealthLink	$138.60
Rate for Payer: BCBS MT Medicare	$138.60
Rate for Payer: BCBS MT POS	$146.30
Rate for Payer: BCBS MT Traditional	$154.00
Rate for Payer: Cash Price	$138.60
Rate for Payer: Cigna Commercial	$146.30
Rate for Payer: Cigna Medicare	$138.60
Rate for Payer: Medicaid All Medicaid	$141.68
Rate for Payer: Medicare All Medicare	$107.80
Rate for Payer: Monida Allegiance	$146.30
Rate for Payer: Monida First Choice Health	$149.38
Rate for Payer: Monida Montana Health Co-op	$146.30
Rate for Payer: Monida PacificSource	$146.30

TR: IRRIGATION OF BLADDER

Facility

$154.00

Service Code	HCPCS 51700
Hospital Charge Code	551700
Hospital Revenue Code	761
Min. Negotiated Rate	$107.80
Max. Negotiated Rate	$154.00
Rate for Payer: Aetna Commercial	$146.30
Rate for Payer: Aetna Medicare	$138.60
Rate for Payer: BCBS MT CHIP	$138.60
Rate for Payer: BCBS MT Closed Plan Network	$146.30
Rate for Payer: BCBS MT HealthLink	$138.60
Rate for Payer: BCBS MT Medicare	$138.60
Rate for Payer: BCBS MT POS	$146.30
Rate for Payer: BCBS MT Traditional	$154.00
Rate for Payer: Cash Price	$138.60
Rate for Payer: Cigna Commercial	$146.30
Rate for Payer: Cigna Medicare	$138.60
Rate for Payer: Medicaid All Medicaid	$141.68
Rate for Payer: Medicare All Medicare	$107.80
Rate for Payer: Monida Allegiance	$146.30
Rate for Payer: Monida First Choice Health	$149.38
Rate for Payer: Monida Montana Health Co-op	$146.30
Rate for Payer: Monida PacificSource	$146.30

TR LUMBAR PUNCTURE

Facility

$2,028.00

Service Code	HCPCS 62270
Hospital Charge Code	1062270
Hospital Revenue Code	761
Min. Negotiated Rate	$1,419.60
Max. Negotiated Rate	$2,028.00
Rate for Payer: Aetna Commercial	$1,926.60
Rate for Payer: Aetna Medicare	$1,825.20
Rate for Payer: BCBS MT CHIP	$1,825.20
Rate for Payer: BCBS MT Closed Plan Network	$1,926.60
Rate for Payer: BCBS MT HealthLink	$1,825.20
Rate for Payer: BCBS MT Medicare	$1,825.20
Rate for Payer: BCBS MT POS	$1,926.60
Rate for Payer: BCBS MT Traditional	$2,028.00
Rate for Payer: Cash Price	$1,825.20
Rate for Payer: Cigna Commercial	$1,926.60
Rate for Payer: Cigna Medicare	$1,825.20
Rate for Payer: Medicaid All Medicaid	$1,865.76
Rate for Payer: Medicare All Medicare	$1,419.60
Rate for Payer: Monida Allegiance	$1,926.60
Rate for Payer: Monida First Choice Health	$1,967.16
Rate for Payer: Monida Montana Health Co-op	$1,926.60
Rate for Payer: Monida PacificSource	$1,926.60

TR LUMBAR PUNCTURE

Facility

$2,028.00

Service Code	HCPCS 62270
Hospital Charge Code	1062270
Hospital Revenue Code	761
Min. Negotiated Rate	$1,419.60
Max. Negotiated Rate	$2,028.00
Rate for Payer: Aetna Commercial	$1,926.60
Rate for Payer: Aetna Medicare	$1,825.20
Rate for Payer: BCBS MT CHIP	$1,825.20
Rate for Payer: BCBS MT Closed Plan Network	$1,926.60
Rate for Payer: BCBS MT HealthLink	$1,825.20
Rate for Payer: BCBS MT Medicare	$1,825.20
Rate for Payer: BCBS MT POS	$1,926.60
Rate for Payer: BCBS MT Traditional	$2,028.00
Rate for Payer: Cash Price	$1,825.20
Rate for Payer: Cigna Commercial	$1,926.60
Rate for Payer: Cigna Medicare	$1,825.20
Rate for Payer: Medicaid All Medicaid	$1,865.76
Rate for Payer: Medicare All Medicare	$1,419.60
Rate for Payer: Monida Allegiance	$1,926.60
Rate for Payer: Monida First Choice Health	$1,967.16
Rate for Payer: Monida Montana Health Co-op	$1,926.60
Rate for Payer: Monida PacificSource	$1,926.60

TR NEG PRESS WOUND TX </=50CM

Facility

$442.00

Service Code	HCPCS 97605
Hospital Charge Code	1097605
Hospital Revenue Code	760
Min. Negotiated Rate	$309.40
Max. Negotiated Rate	$442.00
Rate for Payer: Aetna Commercial	$419.90
Rate for Payer: Aetna Medicare	$397.80
Rate for Payer: BCBS MT CHIP	$397.80
Rate for Payer: BCBS MT Closed Plan Network	$419.90
Rate for Payer: BCBS MT HealthLink	$397.80
Rate for Payer: BCBS MT Medicare	$397.80
Rate for Payer: BCBS MT POS	$419.90
Rate for Payer: BCBS MT Traditional	$442.00
Rate for Payer: Cash Price	$397.80
Rate for Payer: Cigna Commercial	$419.90
Rate for Payer: Cigna Medicare	$397.80
Rate for Payer: Medicaid All Medicaid	$406.64
Rate for Payer: Medicare All Medicare	$309.40
Rate for Payer: Monida Allegiance	$419.90
Rate for Payer: Monida First Choice Health	$428.74
Rate for Payer: Monida Montana Health Co-op	$419.90
Rate for Payer: Monida PacificSource	$419.90

TR NEG PRESS WOUND TX </=50CM

Facility

$442.00

Service Code	HCPCS 97605
Hospital Charge Code	1097605
Hospital Revenue Code	760
Min. Negotiated Rate	$309.40
Max. Negotiated Rate	$442.00
Rate for Payer: Aetna Commercial	$419.90
Rate for Payer: Aetna Medicare	$397.80
Rate for Payer: BCBS MT CHIP	$397.80
Rate for Payer: BCBS MT Closed Plan Network	$419.90
Rate for Payer: BCBS MT HealthLink	$397.80
Rate for Payer: BCBS MT Medicare	$397.80
Rate for Payer: BCBS MT POS	$419.90
Rate for Payer: BCBS MT Traditional	$442.00
Rate for Payer: Cash Price	$397.80
Rate for Payer: Cigna Commercial	$419.90
Rate for Payer: Cigna Medicare	$397.80
Rate for Payer: Medicaid All Medicaid	$406.64
Rate for Payer: Medicare All Medicare	$309.40
Rate for Payer: Monida Allegiance	$419.90
Rate for Payer: Monida First Choice Health	$428.74
Rate for Payer: Monida Montana Health Co-op	$419.90
Rate for Payer: Monida PacificSource	$419.90

TR OF ANKLE FRACTURE

Facility

$504.00

Service Code	HCPCS 27788
Hospital Charge Code	1027788
Hospital Revenue Code	450
Min. Negotiated Rate	$352.80
Max. Negotiated Rate	$504.00
Rate for Payer: Aetna Commercial	$478.80
Rate for Payer: Aetna Medicare	$453.60
Rate for Payer: BCBS MT CHIP	$453.60
Rate for Payer: BCBS MT Closed Plan Network	$478.80
Rate for Payer: BCBS MT HealthLink	$453.60
Rate for Payer: BCBS MT Medicare	$453.60
Rate for Payer: BCBS MT POS	$478.80
Rate for Payer: BCBS MT Traditional	$504.00
Rate for Payer: Cash Price	$453.60
Rate for Payer: Cigna Commercial	$478.80
Rate for Payer: Cigna Medicare	$453.60
Rate for Payer: Medicaid All Medicaid	$463.68
Rate for Payer: Medicare All Medicare	$352.80
Rate for Payer: Monida Allegiance	$478.80
Rate for Payer: Monida First Choice Health	$488.88
Rate for Payer: Monida Montana Health Co-op	$478.80
Rate for Payer: Monida PacificSource	$478.80

TR OF ANKLE FRACTURE

Facility

$504.00

Service Code	HCPCS 27788
Hospital Charge Code	1027788
Hospital Revenue Code	450
Min. Negotiated Rate	$352.80
Max. Negotiated Rate	$504.00
Rate for Payer: Aetna Commercial	$478.80
Rate for Payer: Aetna Medicare	$453.60
Rate for Payer: BCBS MT CHIP	$453.60
Rate for Payer: BCBS MT Closed Plan Network	$478.80
Rate for Payer: BCBS MT HealthLink	$453.60
Rate for Payer: BCBS MT Medicare	$453.60
Rate for Payer: BCBS MT POS	$478.80
Rate for Payer: BCBS MT Traditional	$504.00
Rate for Payer: Cash Price	$453.60
Rate for Payer: Cigna Commercial	$478.80
Rate for Payer: Cigna Medicare	$453.60
Rate for Payer: Medicaid All Medicaid	$463.68
Rate for Payer: Medicare All Medicare	$352.80
Rate for Payer: Monida Allegiance	$478.80
Rate for Payer: Monida First Choice Health	$488.88
Rate for Payer: Monida Montana Health Co-op	$478.80
Rate for Payer: Monida PacificSource	$478.80

TROPONIN I, HIGH SENSITIVITY

Facility

$194.00

Service Code	HCPCS 84484
Hospital Charge Code	4000484
Hospital Revenue Code	300
Min. Negotiated Rate	$135.80
Max. Negotiated Rate	$194.00
Rate for Payer: Aetna Commercial	$184.30
Rate for Payer: Aetna Medicare	$174.60
Rate for Payer: BCBS MT CHIP	$174.60
Rate for Payer: BCBS MT Closed Plan Network	$184.30
Rate for Payer: BCBS MT HealthLink	$174.60
Rate for Payer: BCBS MT Medicare	$174.60
Rate for Payer: BCBS MT POS	$184.30
Rate for Payer: BCBS MT Traditional	$194.00
Rate for Payer: Cash Price	$174.60
Rate for Payer: Cigna Commercial	$184.30
Rate for Payer: Cigna Medicare	$174.60
Rate for Payer: Medicaid All Medicaid	$178.48
Rate for Payer: Medicare All Medicare	$135.80
Rate for Payer: Monida Allegiance	$184.30
Rate for Payer: Monida First Choice Health	$188.18
Rate for Payer: Monida Montana Health Co-op	$184.30
Rate for Payer: Monida PacificSource	$184.30

TROPONIN I, HIGH SENSITIVITY

Facility

$194.00

Service Code	HCPCS 84484
Hospital Charge Code	4000484
Hospital Revenue Code	300
Min. Negotiated Rate	$135.80
Max. Negotiated Rate	$194.00
Rate for Payer: Aetna Commercial	$184.30
Rate for Payer: Aetna Medicare	$174.60
Rate for Payer: BCBS MT CHIP	$174.60
Rate for Payer: BCBS MT Closed Plan Network	$184.30
Rate for Payer: BCBS MT HealthLink	$174.60
Rate for Payer: BCBS MT Medicare	$174.60
Rate for Payer: BCBS MT POS	$184.30
Rate for Payer: BCBS MT Traditional	$194.00
Rate for Payer: Cash Price	$174.60
Rate for Payer: Cigna Commercial	$184.30
Rate for Payer: Cigna Medicare	$174.60
Rate for Payer: Medicaid All Medicaid	$178.48
Rate for Payer: Medicare All Medicare	$135.80
Rate for Payer: Monida Allegiance	$184.30
Rate for Payer: Monida First Choice Health	$188.18
Rate for Payer: Monida Montana Health Co-op	$184.30
Rate for Payer: Monida PacificSource	$184.30

TR REMOVE FOREIGN BODY FROM EAR

Facility

$202.00

Service Code	HCPCS 69200
Hospital Charge Code	569200
Hospital Revenue Code	761
Min. Negotiated Rate	$141.40
Max. Negotiated Rate	$202.00
Rate for Payer: Aetna Commercial	$191.90
Rate for Payer: Aetna Medicare	$181.80
Rate for Payer: BCBS MT CHIP	$181.80
Rate for Payer: BCBS MT Closed Plan Network	$191.90
Rate for Payer: BCBS MT HealthLink	$181.80
Rate for Payer: BCBS MT Medicare	$181.80
Rate for Payer: BCBS MT POS	$191.90
Rate for Payer: BCBS MT Traditional	$202.00
Rate for Payer: Cash Price	$181.80
Rate for Payer: Cigna Commercial	$191.90
Rate for Payer: Cigna Medicare	$181.80
Rate for Payer: Medicaid All Medicaid	$185.84
Rate for Payer: Medicare All Medicare	$141.40
Rate for Payer: Monida Allegiance	$191.90
Rate for Payer: Monida First Choice Health	$195.94
Rate for Payer: Monida Montana Health Co-op	$191.90
Rate for Payer: Monida PacificSource	$191.90

TR REMOVE FOREIGN BODY FROM EAR

Facility

$202.00

Service Code	HCPCS 69200
Hospital Charge Code	569200
Hospital Revenue Code	761
Min. Negotiated Rate	$141.40
Max. Negotiated Rate	$202.00
Rate for Payer: Aetna Commercial	$191.90
Rate for Payer: Aetna Medicare	$181.80
Rate for Payer: BCBS MT CHIP	$181.80
Rate for Payer: BCBS MT Closed Plan Network	$191.90
Rate for Payer: BCBS MT HealthLink	$181.80
Rate for Payer: BCBS MT Medicare	$181.80
Rate for Payer: BCBS MT POS	$191.90
Rate for Payer: BCBS MT Traditional	$202.00
Rate for Payer: Cash Price	$181.80
Rate for Payer: Cigna Commercial	$191.90
Rate for Payer: Cigna Medicare	$181.80
Rate for Payer: Medicaid All Medicaid	$185.84
Rate for Payer: Medicare All Medicare	$141.40
Rate for Payer: Monida Allegiance	$191.90
Rate for Payer: Monida First Choice Health	$195.94
Rate for Payer: Monida Montana Health Co-op	$191.90
Rate for Payer: Monida PacificSource	$191.90

TR REMOVE IMPACTED CERUMEN

Facility

$110.00

Service Code	HCPCS 69209
Hospital Charge Code	569209
Hospital Revenue Code	761
Min. Negotiated Rate	$77.00
Max. Negotiated Rate	$110.00
Rate for Payer: Aetna Commercial	$104.50
Rate for Payer: Aetna Medicare	$99.00
Rate for Payer: BCBS MT CHIP	$99.00
Rate for Payer: BCBS MT Closed Plan Network	$104.50
Rate for Payer: BCBS MT HealthLink	$99.00
Rate for Payer: BCBS MT Medicare	$99.00
Rate for Payer: BCBS MT POS	$104.50
Rate for Payer: BCBS MT Traditional	$110.00
Rate for Payer: Cash Price	$99.00
Rate for Payer: Cigna Commercial	$104.50
Rate for Payer: Cigna Medicare	$99.00
Rate for Payer: Medicaid All Medicaid	$101.20
Rate for Payer: Medicare All Medicare	$77.00
Rate for Payer: Monida Allegiance	$104.50
Rate for Payer: Monida First Choice Health	$106.70
Rate for Payer: Monida Montana Health Co-op	$104.50
Rate for Payer: Monida PacificSource	$104.50

TR REMOVE IMPACTED CERUMEN

Facility

$110.00

Service Code	HCPCS 69209
Hospital Charge Code	569209
Hospital Revenue Code	761
Min. Negotiated Rate	$77.00
Max. Negotiated Rate	$110.00
Rate for Payer: Aetna Commercial	$104.50
Rate for Payer: Aetna Medicare	$99.00
Rate for Payer: BCBS MT CHIP	$99.00
Rate for Payer: BCBS MT Closed Plan Network	$104.50
Rate for Payer: BCBS MT HealthLink	$99.00
Rate for Payer: BCBS MT Medicare	$99.00
Rate for Payer: BCBS MT POS	$104.50
Rate for Payer: BCBS MT Traditional	$110.00
Rate for Payer: Cash Price	$99.00
Rate for Payer: Cigna Commercial	$104.50
Rate for Payer: Cigna Medicare	$99.00
Rate for Payer: Medicaid All Medicaid	$101.20
Rate for Payer: Medicare All Medicare	$77.00
Rate for Payer: Monida Allegiance	$104.50
Rate for Payer: Monida First Choice Health	$106.70
Rate for Payer: Monida Montana Health Co-op	$104.50
Rate for Payer: Monida PacificSource	$104.50

TR REMOVE IMPACTED EAR WAX/INST

Facility

$127.00

Service Code	HCPCS 69210
Hospital Charge Code	569210
Hospital Revenue Code	761
Min. Negotiated Rate	$88.90
Max. Negotiated Rate	$127.00
Rate for Payer: Aetna Commercial	$120.65
Rate for Payer: Aetna Medicare	$114.30
Rate for Payer: BCBS MT CHIP	$114.30
Rate for Payer: BCBS MT Closed Plan Network	$120.65
Rate for Payer: BCBS MT HealthLink	$114.30
Rate for Payer: BCBS MT Medicare	$114.30
Rate for Payer: BCBS MT POS	$120.65
Rate for Payer: BCBS MT Traditional	$127.00
Rate for Payer: Cash Price	$114.30
Rate for Payer: Cigna Commercial	$120.65
Rate for Payer: Cigna Medicare	$114.30
Rate for Payer: Medicaid All Medicaid	$116.84
Rate for Payer: Medicare All Medicare	$88.90
Rate for Payer: Monida Allegiance	$120.65
Rate for Payer: Monida First Choice Health	$123.19
Rate for Payer: Monida Montana Health Co-op	$120.65
Rate for Payer: Monida PacificSource	$120.65

TR REMOVE IMPACTED EAR WAX/INST

Facility

$127.00

Service Code	HCPCS 69210
Hospital Charge Code	569210
Hospital Revenue Code	761
Min. Negotiated Rate	$88.90
Max. Negotiated Rate	$127.00
Rate for Payer: Aetna Commercial	$120.65
Rate for Payer: Aetna Medicare	$114.30
Rate for Payer: BCBS MT CHIP	$114.30
Rate for Payer: BCBS MT Closed Plan Network	$120.65
Rate for Payer: BCBS MT HealthLink	$114.30
Rate for Payer: BCBS MT Medicare	$114.30
Rate for Payer: BCBS MT POS	$120.65
Rate for Payer: BCBS MT Traditional	$127.00
Rate for Payer: Cash Price	$114.30
Rate for Payer: Cigna Commercial	$120.65
Rate for Payer: Cigna Medicare	$114.30
Rate for Payer: Medicaid All Medicaid	$116.84
Rate for Payer: Medicare All Medicare	$88.90
Rate for Payer: Monida Allegiance	$120.65
Rate for Payer: Monida First Choice Health	$123.19
Rate for Payer: Monida Montana Health Co-op	$120.65
Rate for Payer: Monida PacificSource	$120.65

TRYPTASE (004280)

Facility

$263.00

Service Code	HCPCS 83520
Hospital Charge Code	4000057
Hospital Revenue Code	301
Min. Negotiated Rate	$184.10
Max. Negotiated Rate	$263.00
Rate for Payer: Aetna Commercial	$249.85
Rate for Payer: Aetna Medicare	$236.70
Rate for Payer: BCBS MT CHIP	$236.70
Rate for Payer: BCBS MT Closed Plan Network	$249.85
Rate for Payer: BCBS MT HealthLink	$236.70
Rate for Payer: BCBS MT Medicare	$236.70
Rate for Payer: BCBS MT POS	$249.85
Rate for Payer: BCBS MT Traditional	$263.00
Rate for Payer: Cash Price	$236.70
Rate for Payer: Cigna Commercial	$249.85
Rate for Payer: Cigna Medicare	$236.70
Rate for Payer: Medicaid All Medicaid	$241.96
Rate for Payer: Medicare All Medicare	$184.10
Rate for Payer: Monida Allegiance	$249.85
Rate for Payer: Monida First Choice Health	$255.11
Rate for Payer: Monida Montana Health Co-op	$249.85
Rate for Payer: Monida PacificSource	$249.85

TRYPTASE (004280)

Facility

$263.00

Service Code	HCPCS 83520
Hospital Charge Code	4000057
Hospital Revenue Code	301
Min. Negotiated Rate	$184.10
Max. Negotiated Rate	$263.00
Rate for Payer: Aetna Commercial	$249.85
Rate for Payer: Aetna Medicare	$236.70
Rate for Payer: BCBS MT CHIP	$236.70
Rate for Payer: BCBS MT Closed Plan Network	$249.85
Rate for Payer: BCBS MT HealthLink	$236.70
Rate for Payer: BCBS MT Medicare	$236.70
Rate for Payer: BCBS MT POS	$249.85
Rate for Payer: BCBS MT Traditional	$263.00
Rate for Payer: Cash Price	$236.70
Rate for Payer: Cigna Commercial	$249.85
Rate for Payer: Cigna Medicare	$236.70
Rate for Payer: Medicaid All Medicaid	$241.96
Rate for Payer: Medicare All Medicare	$184.10
Rate for Payer: Monida Allegiance	$249.85
Rate for Payer: Monida First Choice Health	$255.11
Rate for Payer: Monida Montana Health Co-op	$249.85
Rate for Payer: Monida PacificSource	$249.85

TSH

Facility

$167.00

Service Code	HCPCS 84443
Hospital Charge Code	4084443
Hospital Revenue Code	301
Min. Negotiated Rate	$116.90
Max. Negotiated Rate	$167.00
Rate for Payer: Aetna Commercial	$158.65
Rate for Payer: Aetna Medicare	$150.30
Rate for Payer: BCBS MT CHIP	$150.30
Rate for Payer: BCBS MT Closed Plan Network	$158.65
Rate for Payer: BCBS MT HealthLink	$150.30
Rate for Payer: BCBS MT Medicare	$150.30
Rate for Payer: BCBS MT POS	$158.65
Rate for Payer: BCBS MT Traditional	$167.00
Rate for Payer: Cash Price	$150.30
Rate for Payer: Cigna Commercial	$158.65
Rate for Payer: Cigna Medicare	$150.30
Rate for Payer: Medicaid All Medicaid	$153.64
Rate for Payer: Medicare All Medicare	$116.90
Rate for Payer: Monida Allegiance	$158.65
Rate for Payer: Monida First Choice Health	$161.99
Rate for Payer: Monida Montana Health Co-op	$158.65
Rate for Payer: Monida PacificSource	$158.65

TSH

Facility

$167.00

Service Code	HCPCS 84443
Hospital Charge Code	4084443
Hospital Revenue Code	301
Min. Negotiated Rate	$116.90
Max. Negotiated Rate	$167.00
Rate for Payer: Aetna Commercial	$158.65
Rate for Payer: Aetna Medicare	$150.30
Rate for Payer: BCBS MT CHIP	$150.30
Rate for Payer: BCBS MT Closed Plan Network	$158.65
Rate for Payer: BCBS MT HealthLink	$150.30
Rate for Payer: BCBS MT Medicare	$150.30
Rate for Payer: BCBS MT POS	$158.65
Rate for Payer: BCBS MT Traditional	$167.00
Rate for Payer: Cash Price	$150.30
Rate for Payer: Cigna Commercial	$158.65
Rate for Payer: Cigna Medicare	$150.30
Rate for Payer: Medicaid All Medicaid	$153.64
Rate for Payer: Medicare All Medicare	$116.90
Rate for Payer: Monida Allegiance	$158.65
Rate for Payer: Monida First Choice Health	$161.99
Rate for Payer: Monida Montana Health Co-op	$158.65
Rate for Payer: Monida PacificSource	$158.65

TSH W/ REFLEX

Facility

$167.00

Service Code	HCPCS 84443
Hospital Charge Code	4044431
Hospital Revenue Code	301
Min. Negotiated Rate	$116.90
Max. Negotiated Rate	$167.00
Rate for Payer: Aetna Commercial	$158.65
Rate for Payer: Aetna Medicare	$150.30
Rate for Payer: BCBS MT CHIP	$150.30
Rate for Payer: BCBS MT Closed Plan Network	$158.65
Rate for Payer: BCBS MT HealthLink	$150.30
Rate for Payer: BCBS MT Medicare	$150.30
Rate for Payer: BCBS MT POS	$158.65
Rate for Payer: BCBS MT Traditional	$167.00
Rate for Payer: Cash Price	$150.30
Rate for Payer: Cigna Commercial	$158.65
Rate for Payer: Cigna Medicare	$150.30
Rate for Payer: Medicaid All Medicaid	$153.64
Rate for Payer: Medicare All Medicare	$116.90
Rate for Payer: Monida Allegiance	$158.65
Rate for Payer: Monida First Choice Health	$161.99
Rate for Payer: Monida Montana Health Co-op	$158.65
Rate for Payer: Monida PacificSource	$158.65

TSH W/ REFLEX

Facility

$167.00

Service Code	HCPCS 84443
Hospital Charge Code	4044431
Hospital Revenue Code	301
Min. Negotiated Rate	$116.90
Max. Negotiated Rate	$167.00
Rate for Payer: Aetna Commercial	$158.65
Rate for Payer: Aetna Medicare	$150.30
Rate for Payer: BCBS MT CHIP	$150.30
Rate for Payer: BCBS MT Closed Plan Network	$158.65
Rate for Payer: BCBS MT HealthLink	$150.30
Rate for Payer: BCBS MT Medicare	$150.30
Rate for Payer: BCBS MT POS	$158.65
Rate for Payer: BCBS MT Traditional	$167.00
Rate for Payer: Cash Price	$150.30
Rate for Payer: Cigna Commercial	$158.65
Rate for Payer: Cigna Medicare	$150.30
Rate for Payer: Medicaid All Medicaid	$153.64
Rate for Payer: Medicare All Medicare	$116.90
Rate for Payer: Monida Allegiance	$158.65
Rate for Payer: Monida First Choice Health	$161.99
Rate for Payer: Monida Montana Health Co-op	$158.65
Rate for Payer: Monida PacificSource	$158.65

Know your out-of-pocket cost for care.

All Charges