Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

CATHETER - CL - INSERT INDWELLING

Facility

$207.00

Service Code	HCPCS 51702
Hospital Charge Code	8051702
Hospital Revenue Code	761
Min. Negotiated Rate	$144.90
Max. Negotiated Rate	$207.00
Rate for Payer: Aetna Commercial	$196.65
Rate for Payer: Aetna Medicare	$186.30
Rate for Payer: BCBS MT CHIP	$186.30
Rate for Payer: BCBS MT Closed Plan Network	$196.65
Rate for Payer: BCBS MT HealthLink	$186.30
Rate for Payer: BCBS MT Medicare	$186.30
Rate for Payer: BCBS MT POS	$196.65
Rate for Payer: BCBS MT Traditional	$207.00
Rate for Payer: Cash Price	$186.30
Rate for Payer: Cigna Commercial	$196.65
Rate for Payer: Cigna Medicare	$186.30
Rate for Payer: Medicaid All Medicaid	$190.44
Rate for Payer: Medicare All Medicare	$144.90
Rate for Payer: Monida Allegiance	$196.65
Rate for Payer: Monida First Choice Health	$200.79
Rate for Payer: Monida Montana Health Co-op	$196.65
Rate for Payer: Monida PacificSource	$196.65

CATHETER - CL - INSERT INDWELLING

Facility

$207.00

Service Code	HCPCS 51702
Hospital Charge Code	8051702
Hospital Revenue Code	761
Min. Negotiated Rate	$144.90
Max. Negotiated Rate	$207.00
Rate for Payer: Aetna Commercial	$196.65
Rate for Payer: Aetna Medicare	$186.30
Rate for Payer: BCBS MT CHIP	$186.30
Rate for Payer: BCBS MT Closed Plan Network	$196.65
Rate for Payer: BCBS MT HealthLink	$186.30
Rate for Payer: BCBS MT Medicare	$186.30
Rate for Payer: BCBS MT POS	$196.65
Rate for Payer: BCBS MT Traditional	$207.00
Rate for Payer: Cash Price	$186.30
Rate for Payer: Cigna Commercial	$196.65
Rate for Payer: Cigna Medicare	$186.30
Rate for Payer: Medicaid All Medicaid	$190.44
Rate for Payer: Medicare All Medicare	$144.90
Rate for Payer: Monida Allegiance	$196.65
Rate for Payer: Monida First Choice Health	$200.79
Rate for Payer: Monida Montana Health Co-op	$196.65
Rate for Payer: Monida PacificSource	$196.65

CATHETER COUDE 14FR 5CC

Facility

$72.00

Hospital Charge Code	80010119
Hospital Revenue Code	270
Min. Negotiated Rate	$50.40
Max. Negotiated Rate	$72.00
Rate for Payer: Aetna Commercial	$68.40
Rate for Payer: Aetna Medicare	$64.80
Rate for Payer: BCBS MT CHIP	$64.80
Rate for Payer: BCBS MT Closed Plan Network	$68.40
Rate for Payer: BCBS MT HealthLink	$64.80
Rate for Payer: BCBS MT Medicare	$64.80
Rate for Payer: BCBS MT POS	$68.40
Rate for Payer: BCBS MT Traditional	$72.00
Rate for Payer: Cash Price	$64.80
Rate for Payer: Cigna Commercial	$68.40
Rate for Payer: Cigna Medicare	$64.80
Rate for Payer: Medicaid All Medicaid	$66.24
Rate for Payer: Medicare All Medicare	$50.40
Rate for Payer: Monida Allegiance	$68.40
Rate for Payer: Monida First Choice Health	$69.84
Rate for Payer: Monida Montana Health Co-op	$68.40
Rate for Payer: Monida PacificSource	$68.40

CATHETER COUDE 14FR 5CC

Facility

$72.00

Hospital Charge Code	80010119
Hospital Revenue Code	270
Min. Negotiated Rate	$50.40
Max. Negotiated Rate	$72.00
Rate for Payer: Aetna Commercial	$68.40
Rate for Payer: Aetna Medicare	$64.80
Rate for Payer: BCBS MT CHIP	$64.80
Rate for Payer: BCBS MT Closed Plan Network	$68.40
Rate for Payer: BCBS MT HealthLink	$64.80
Rate for Payer: BCBS MT Medicare	$64.80
Rate for Payer: BCBS MT POS	$68.40
Rate for Payer: BCBS MT Traditional	$72.00
Rate for Payer: Cash Price	$64.80
Rate for Payer: Cigna Commercial	$68.40
Rate for Payer: Cigna Medicare	$64.80
Rate for Payer: Medicaid All Medicaid	$66.24
Rate for Payer: Medicare All Medicare	$50.40
Rate for Payer: Monida Allegiance	$68.40
Rate for Payer: Monida First Choice Health	$69.84
Rate for Payer: Monida Montana Health Co-op	$68.40
Rate for Payer: Monida PacificSource	$68.40

CATHETER - ER - INSERT INDWELLING

Facility

$207.00

Service Code	HCPCS 51702
Hospital Charge Code	1051702
Hospital Revenue Code	450
Min. Negotiated Rate	$144.90
Max. Negotiated Rate	$207.00
Rate for Payer: Aetna Commercial	$196.65
Rate for Payer: Aetna Medicare	$186.30
Rate for Payer: BCBS MT CHIP	$186.30
Rate for Payer: BCBS MT Closed Plan Network	$196.65
Rate for Payer: BCBS MT HealthLink	$186.30
Rate for Payer: BCBS MT Medicare	$186.30
Rate for Payer: BCBS MT POS	$196.65
Rate for Payer: BCBS MT Traditional	$207.00
Rate for Payer: Cash Price	$186.30
Rate for Payer: Cigna Commercial	$196.65
Rate for Payer: Cigna Medicare	$186.30
Rate for Payer: Medicaid All Medicaid	$190.44
Rate for Payer: Medicare All Medicare	$144.90
Rate for Payer: Monida Allegiance	$196.65
Rate for Payer: Monida First Choice Health	$200.79
Rate for Payer: Monida Montana Health Co-op	$196.65
Rate for Payer: Monida PacificSource	$196.65

CATHETER - ER - INSERT INDWELLING

Facility

$207.00

Service Code	HCPCS 51702
Hospital Charge Code	1051702
Hospital Revenue Code	450
Min. Negotiated Rate	$144.90
Max. Negotiated Rate	$207.00
Rate for Payer: Aetna Commercial	$196.65
Rate for Payer: Aetna Medicare	$186.30
Rate for Payer: BCBS MT CHIP	$186.30
Rate for Payer: BCBS MT Closed Plan Network	$196.65
Rate for Payer: BCBS MT HealthLink	$186.30
Rate for Payer: BCBS MT Medicare	$186.30
Rate for Payer: BCBS MT POS	$196.65
Rate for Payer: BCBS MT Traditional	$207.00
Rate for Payer: Cash Price	$186.30
Rate for Payer: Cigna Commercial	$196.65
Rate for Payer: Cigna Medicare	$186.30
Rate for Payer: Medicaid All Medicaid	$190.44
Rate for Payer: Medicare All Medicare	$144.90
Rate for Payer: Monida Allegiance	$196.65
Rate for Payer: Monida First Choice Health	$200.79
Rate for Payer: Monida Montana Health Co-op	$196.65
Rate for Payer: Monida PacificSource	$196.65

CATHETER - ER - INSERT NON-INDWELLING

Facility

$193.00

Service Code	HCPCS 51701
Hospital Charge Code	1051701
Hospital Revenue Code	450
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

CATHETER - ER - INSERT NON-INDWELLING

Facility

$193.00

Service Code	HCPCS 51701
Hospital Charge Code	1051701
Hospital Revenue Code	450
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

CATHETER IV INTROCAN 24G 5/8

Facility

$25.00

Hospital Charge Code	80030203
Hospital Revenue Code	270
Min. Negotiated Rate	$17.50
Max. Negotiated Rate	$25.00
Rate for Payer: Aetna Commercial	$23.75
Rate for Payer: Aetna Medicare	$22.50
Rate for Payer: BCBS MT CHIP	$22.50
Rate for Payer: BCBS MT Closed Plan Network	$23.75
Rate for Payer: BCBS MT HealthLink	$22.50
Rate for Payer: BCBS MT Medicare	$22.50
Rate for Payer: BCBS MT POS	$23.75
Rate for Payer: BCBS MT Traditional	$25.00
Rate for Payer: Cash Price	$22.50
Rate for Payer: Cigna Commercial	$23.75
Rate for Payer: Cigna Medicare	$22.50
Rate for Payer: Medicaid All Medicaid	$23.00
Rate for Payer: Medicare All Medicare	$17.50
Rate for Payer: Monida Allegiance	$23.75
Rate for Payer: Monida First Choice Health	$24.25
Rate for Payer: Monida Montana Health Co-op	$23.75
Rate for Payer: Monida PacificSource	$23.75

CATHETER IV INTROCAN 24G 5/8

Facility

$25.00

Hospital Charge Code	80030203
Hospital Revenue Code	270
Min. Negotiated Rate	$17.50
Max. Negotiated Rate	$25.00
Rate for Payer: Aetna Commercial	$23.75
Rate for Payer: Aetna Medicare	$22.50
Rate for Payer: BCBS MT CHIP	$22.50
Rate for Payer: BCBS MT Closed Plan Network	$23.75
Rate for Payer: BCBS MT HealthLink	$22.50
Rate for Payer: BCBS MT Medicare	$22.50
Rate for Payer: BCBS MT POS	$23.75
Rate for Payer: BCBS MT Traditional	$25.00
Rate for Payer: Cash Price	$22.50
Rate for Payer: Cigna Commercial	$23.75
Rate for Payer: Cigna Medicare	$22.50
Rate for Payer: Medicaid All Medicaid	$23.00
Rate for Payer: Medicare All Medicare	$17.50
Rate for Payer: Monida Allegiance	$23.75
Rate for Payer: Monida First Choice Health	$24.25
Rate for Payer: Monida Montana Health Co-op	$23.75
Rate for Payer: Monida PacificSource	$23.75

CATHETER SELF 14FR

Facility

$72.00

Hospital Charge Code	80040166
Hospital Revenue Code	270
Min. Negotiated Rate	$50.40
Max. Negotiated Rate	$72.00
Rate for Payer: Aetna Commercial	$68.40
Rate for Payer: Aetna Medicare	$64.80
Rate for Payer: BCBS MT CHIP	$64.80
Rate for Payer: BCBS MT Closed Plan Network	$68.40
Rate for Payer: BCBS MT HealthLink	$64.80
Rate for Payer: BCBS MT Medicare	$64.80
Rate for Payer: BCBS MT POS	$68.40
Rate for Payer: BCBS MT Traditional	$72.00
Rate for Payer: Cash Price	$64.80
Rate for Payer: Cigna Commercial	$68.40
Rate for Payer: Cigna Medicare	$64.80
Rate for Payer: Medicaid All Medicaid	$66.24
Rate for Payer: Medicare All Medicare	$50.40
Rate for Payer: Monida Allegiance	$68.40
Rate for Payer: Monida First Choice Health	$69.84
Rate for Payer: Monida Montana Health Co-op	$68.40
Rate for Payer: Monida PacificSource	$68.40

CATHETER SELF 14FR

Facility

$72.00

Hospital Charge Code	80040166
Hospital Revenue Code	270
Min. Negotiated Rate	$50.40
Max. Negotiated Rate	$72.00
Rate for Payer: Aetna Commercial	$68.40
Rate for Payer: Aetna Medicare	$64.80
Rate for Payer: BCBS MT CHIP	$64.80
Rate for Payer: BCBS MT Closed Plan Network	$68.40
Rate for Payer: BCBS MT HealthLink	$64.80
Rate for Payer: BCBS MT Medicare	$64.80
Rate for Payer: BCBS MT POS	$68.40
Rate for Payer: BCBS MT Traditional	$72.00
Rate for Payer: Cash Price	$64.80
Rate for Payer: Cigna Commercial	$68.40
Rate for Payer: Cigna Medicare	$64.80
Rate for Payer: Medicaid All Medicaid	$66.24
Rate for Payer: Medicare All Medicare	$50.40
Rate for Payer: Monida Allegiance	$68.40
Rate for Payer: Monida First Choice Health	$69.84
Rate for Payer: Monida Montana Health Co-op	$68.40
Rate for Payer: Monida PacificSource	$68.40

CATHETER STRAP

Facility

$24.00

Hospital Charge Code	80030424
Hospital Revenue Code	270
Min. Negotiated Rate	$16.80
Max. Negotiated Rate	$24.00
Rate for Payer: Aetna Commercial	$22.80
Rate for Payer: Aetna Medicare	$21.60
Rate for Payer: BCBS MT CHIP	$21.60
Rate for Payer: BCBS MT Closed Plan Network	$22.80
Rate for Payer: BCBS MT HealthLink	$21.60
Rate for Payer: BCBS MT Medicare	$21.60
Rate for Payer: BCBS MT POS	$22.80
Rate for Payer: BCBS MT Traditional	$24.00
Rate for Payer: Cash Price	$21.60
Rate for Payer: Cigna Commercial	$22.80
Rate for Payer: Cigna Medicare	$21.60
Rate for Payer: Medicaid All Medicaid	$22.08
Rate for Payer: Medicare All Medicare	$16.80
Rate for Payer: Monida Allegiance	$22.80
Rate for Payer: Monida First Choice Health	$23.28
Rate for Payer: Monida Montana Health Co-op	$22.80
Rate for Payer: Monida PacificSource	$22.80

CATHETER STRAP

Facility

$24.00

Hospital Charge Code	80030424
Hospital Revenue Code	270
Min. Negotiated Rate	$16.80
Max. Negotiated Rate	$24.00
Rate for Payer: Aetna Commercial	$22.80
Rate for Payer: Aetna Medicare	$21.60
Rate for Payer: BCBS MT CHIP	$21.60
Rate for Payer: BCBS MT Closed Plan Network	$22.80
Rate for Payer: BCBS MT HealthLink	$21.60
Rate for Payer: BCBS MT Medicare	$21.60
Rate for Payer: BCBS MT POS	$22.80
Rate for Payer: BCBS MT Traditional	$24.00
Rate for Payer: Cash Price	$21.60
Rate for Payer: Cigna Commercial	$22.80
Rate for Payer: Cigna Medicare	$21.60
Rate for Payer: Medicaid All Medicaid	$22.08
Rate for Payer: Medicare All Medicare	$16.80
Rate for Payer: Monida Allegiance	$22.80
Rate for Payer: Monida First Choice Health	$23.28
Rate for Payer: Monida Montana Health Co-op	$22.80
Rate for Payer: Monida PacificSource	$22.80

CATHETER - TR - INSERT INDWELLING

Facility

$207.00

Service Code	HCPCS 51702
Hospital Charge Code	551702
Hospital Revenue Code	761
Min. Negotiated Rate	$144.90
Max. Negotiated Rate	$207.00
Rate for Payer: Aetna Commercial	$196.65
Rate for Payer: Aetna Medicare	$186.30
Rate for Payer: BCBS MT CHIP	$186.30
Rate for Payer: BCBS MT Closed Plan Network	$196.65
Rate for Payer: BCBS MT HealthLink	$186.30
Rate for Payer: BCBS MT Medicare	$186.30
Rate for Payer: BCBS MT POS	$196.65
Rate for Payer: BCBS MT Traditional	$207.00
Rate for Payer: Cash Price	$186.30
Rate for Payer: Cigna Commercial	$196.65
Rate for Payer: Cigna Medicare	$186.30
Rate for Payer: Medicaid All Medicaid	$190.44
Rate for Payer: Medicare All Medicare	$144.90
Rate for Payer: Monida Allegiance	$196.65
Rate for Payer: Monida First Choice Health	$200.79
Rate for Payer: Monida Montana Health Co-op	$196.65
Rate for Payer: Monida PacificSource	$196.65

CATHETER - TR - INSERT INDWELLING

Facility

$207.00

Service Code	HCPCS 51702
Hospital Charge Code	551702
Hospital Revenue Code	761
Min. Negotiated Rate	$144.90
Max. Negotiated Rate	$207.00
Rate for Payer: Aetna Commercial	$196.65
Rate for Payer: Aetna Medicare	$186.30
Rate for Payer: BCBS MT CHIP	$186.30
Rate for Payer: BCBS MT Closed Plan Network	$196.65
Rate for Payer: BCBS MT HealthLink	$186.30
Rate for Payer: BCBS MT Medicare	$186.30
Rate for Payer: BCBS MT POS	$196.65
Rate for Payer: BCBS MT Traditional	$207.00
Rate for Payer: Cash Price	$186.30
Rate for Payer: Cigna Commercial	$196.65
Rate for Payer: Cigna Medicare	$186.30
Rate for Payer: Medicaid All Medicaid	$190.44
Rate for Payer: Medicare All Medicare	$144.90
Rate for Payer: Monida Allegiance	$196.65
Rate for Payer: Monida First Choice Health	$200.79
Rate for Payer: Monida Montana Health Co-op	$196.65
Rate for Payer: Monida PacificSource	$196.65

CATHETER - TR - INSERT NON-INDWELLING

Facility

$193.00

Service Code	HCPCS 51701
Hospital Charge Code	551701
Hospital Revenue Code	761
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

CATHETER - TR - INSERT NON-INDWELLING

Facility

$193.00

Service Code	HCPCS 51701
Hospital Charge Code	551701
Hospital Revenue Code	761
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

CAUTERY HIGHTEMP LOOPTIP

Facility

$59.00

Hospital Charge Code	80030082
Hospital Revenue Code	270
Min. Negotiated Rate	$41.30
Max. Negotiated Rate	$59.00
Rate for Payer: Aetna Commercial	$56.05
Rate for Payer: Aetna Medicare	$53.10
Rate for Payer: BCBS MT CHIP	$53.10
Rate for Payer: BCBS MT Closed Plan Network	$56.05
Rate for Payer: BCBS MT HealthLink	$53.10
Rate for Payer: BCBS MT Medicare	$53.10
Rate for Payer: BCBS MT POS	$56.05
Rate for Payer: BCBS MT Traditional	$59.00
Rate for Payer: Cash Price	$53.10
Rate for Payer: Cigna Commercial	$56.05
Rate for Payer: Cigna Medicare	$53.10
Rate for Payer: Medicaid All Medicaid	$54.28
Rate for Payer: Medicare All Medicare	$41.30
Rate for Payer: Monida Allegiance	$56.05
Rate for Payer: Monida First Choice Health	$57.23
Rate for Payer: Monida Montana Health Co-op	$56.05
Rate for Payer: Monida PacificSource	$56.05

CAUTERY HIGHTEMP LOOPTIP

Facility

$59.00

Hospital Charge Code	80030082
Hospital Revenue Code	270
Min. Negotiated Rate	$41.30
Max. Negotiated Rate	$59.00
Rate for Payer: Aetna Commercial	$56.05
Rate for Payer: Aetna Medicare	$53.10
Rate for Payer: BCBS MT CHIP	$53.10
Rate for Payer: BCBS MT Closed Plan Network	$56.05
Rate for Payer: BCBS MT HealthLink	$53.10
Rate for Payer: BCBS MT Medicare	$53.10
Rate for Payer: BCBS MT POS	$56.05
Rate for Payer: BCBS MT Traditional	$59.00
Rate for Payer: Cash Price	$53.10
Rate for Payer: Cigna Commercial	$56.05
Rate for Payer: Cigna Medicare	$53.10
Rate for Payer: Medicaid All Medicaid	$54.28
Rate for Payer: Medicare All Medicare	$41.30
Rate for Payer: Monida Allegiance	$56.05
Rate for Payer: Monida First Choice Health	$57.23
Rate for Payer: Monida Montana Health Co-op	$56.05
Rate for Payer: Monida PacificSource	$56.05

CBC W/ MANUAL DIFF

Facility

$88.00

Service Code	HCPCS 85027
Hospital Charge Code	4050272
Hospital Revenue Code	305
Min. Negotiated Rate	$61.60
Max. Negotiated Rate	$88.00
Rate for Payer: Aetna Commercial	$83.60
Rate for Payer: Aetna Medicare	$79.20
Rate for Payer: BCBS MT CHIP	$79.20
Rate for Payer: BCBS MT Closed Plan Network	$83.60
Rate for Payer: BCBS MT HealthLink	$79.20
Rate for Payer: BCBS MT Medicare	$79.20
Rate for Payer: BCBS MT POS	$83.60
Rate for Payer: BCBS MT Traditional	$88.00
Rate for Payer: Cash Price	$79.20
Rate for Payer: Cigna Commercial	$83.60
Rate for Payer: Cigna Medicare	$79.20
Rate for Payer: Medicaid All Medicaid	$80.96
Rate for Payer: Medicare All Medicare	$61.60
Rate for Payer: Monida Allegiance	$83.60
Rate for Payer: Monida First Choice Health	$85.36
Rate for Payer: Monida Montana Health Co-op	$83.60
Rate for Payer: Monida PacificSource	$83.60

CBC W/ MANUAL DIFF

Facility

$88.00

Service Code	HCPCS 85027
Hospital Charge Code	4050272
Hospital Revenue Code	305
Min. Negotiated Rate	$61.60
Max. Negotiated Rate	$88.00
Rate for Payer: Aetna Commercial	$83.60
Rate for Payer: Aetna Medicare	$79.20
Rate for Payer: BCBS MT CHIP	$79.20
Rate for Payer: BCBS MT Closed Plan Network	$83.60
Rate for Payer: BCBS MT HealthLink	$79.20
Rate for Payer: BCBS MT Medicare	$79.20
Rate for Payer: BCBS MT POS	$83.60
Rate for Payer: BCBS MT Traditional	$88.00
Rate for Payer: Cash Price	$79.20
Rate for Payer: Cigna Commercial	$83.60
Rate for Payer: Cigna Medicare	$79.20
Rate for Payer: Medicaid All Medicaid	$80.96
Rate for Payer: Medicare All Medicare	$61.60
Rate for Payer: Monida Allegiance	$83.60
Rate for Payer: Monida First Choice Health	$85.36
Rate for Payer: Monida Montana Health Co-op	$83.60
Rate for Payer: Monida PacificSource	$83.60

CBC W/O DIFF

Facility

$88.00

Service Code	HCPCS 85027
Hospital Charge Code	4050271
Hospital Revenue Code	305
Min. Negotiated Rate	$61.60
Max. Negotiated Rate	$88.00
Rate for Payer: Aetna Commercial	$83.60
Rate for Payer: Aetna Medicare	$79.20
Rate for Payer: BCBS MT CHIP	$79.20
Rate for Payer: BCBS MT Closed Plan Network	$83.60
Rate for Payer: BCBS MT HealthLink	$79.20
Rate for Payer: BCBS MT Medicare	$79.20
Rate for Payer: BCBS MT POS	$83.60
Rate for Payer: BCBS MT Traditional	$88.00
Rate for Payer: Cash Price	$79.20
Rate for Payer: Cigna Commercial	$83.60
Rate for Payer: Cigna Medicare	$79.20
Rate for Payer: Medicaid All Medicaid	$80.96
Rate for Payer: Medicare All Medicare	$61.60
Rate for Payer: Monida Allegiance	$83.60
Rate for Payer: Monida First Choice Health	$85.36
Rate for Payer: Monida Montana Health Co-op	$83.60
Rate for Payer: Monida PacificSource	$83.60

CBC W/O DIFF

Facility

$88.00

Service Code	HCPCS 85027
Hospital Charge Code	4050271
Hospital Revenue Code	305
Min. Negotiated Rate	$61.60
Max. Negotiated Rate	$88.00
Rate for Payer: Aetna Commercial	$83.60
Rate for Payer: Aetna Medicare	$79.20
Rate for Payer: BCBS MT CHIP	$79.20
Rate for Payer: BCBS MT Closed Plan Network	$83.60
Rate for Payer: BCBS MT HealthLink	$79.20
Rate for Payer: BCBS MT Medicare	$79.20
Rate for Payer: BCBS MT POS	$83.60
Rate for Payer: BCBS MT Traditional	$88.00
Rate for Payer: Cash Price	$79.20
Rate for Payer: Cigna Commercial	$83.60
Rate for Payer: Cigna Medicare	$79.20
Rate for Payer: Medicaid All Medicaid	$80.96
Rate for Payer: Medicare All Medicare	$61.60
Rate for Payer: Monida Allegiance	$83.60
Rate for Payer: Monida First Choice Health	$85.36
Rate for Payer: Monida Montana Health Co-op	$83.60
Rate for Payer: Monida PacificSource	$83.60

CCP AB, IGG/IGA (164914)

Facility

$53.00

Service Code	HCPCS 86200
Hospital Charge Code	4086200
Hospital Revenue Code	300
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

Know your out-of-pocket cost for care.

All Charges