Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

REMOVAL FB SUBCUTAN TISSUE SIMPLE

Facility

$527.00

Service Code	CPT 10120
Hospital Charge Code	8010120
Hospital Revenue Code	521
Min. Negotiated Rate	$368.90
Max. Negotiated Rate	$527.00
Rate for Payer: Aetna Commercial	$500.65
Rate for Payer: Aetna Medicare	$474.30
Rate for Payer: BCBS MT CHIP	$474.30
Rate for Payer: BCBS MT Closed Plan Network	$500.65
Rate for Payer: BCBS MT HealthLink	$474.30
Rate for Payer: BCBS MT Medicare	$474.30
Rate for Payer: BCBS MT POS	$500.65
Rate for Payer: BCBS MT Traditional	$527.00
Rate for Payer: Cash Price	$474.30
Rate for Payer: Cigna Commercial	$500.65
Rate for Payer: Cigna Medicare	$474.30
Rate for Payer: Medicaid All Medicaid	$484.84
Rate for Payer: Medicare All Medicare	$368.90
Rate for Payer: Monida Allegiance	$500.65
Rate for Payer: Monida First Choice Health	$511.19
Rate for Payer: Monida Montana Health Co-op	$500.65
Rate for Payer: Monida PacificSource	$500.65

REMOVAL FB SUBCUTAN TISSUE SIMPLE

Facility

$527.00

Service Code	CPT 10120
Hospital Charge Code	8010120
Hospital Revenue Code	521
Min. Negotiated Rate	$368.90
Max. Negotiated Rate	$527.00
Rate for Payer: Aetna Commercial	$500.65
Rate for Payer: Aetna Medicare	$474.30
Rate for Payer: BCBS MT CHIP	$474.30
Rate for Payer: BCBS MT Closed Plan Network	$500.65
Rate for Payer: BCBS MT HealthLink	$474.30
Rate for Payer: BCBS MT Medicare	$474.30
Rate for Payer: BCBS MT POS	$500.65
Rate for Payer: BCBS MT Traditional	$527.00
Rate for Payer: Cash Price	$474.30
Rate for Payer: Cigna Commercial	$500.65
Rate for Payer: Cigna Medicare	$474.30
Rate for Payer: Medicaid All Medicaid	$484.84
Rate for Payer: Medicare All Medicare	$368.90
Rate for Payer: Monida Allegiance	$500.65
Rate for Payer: Monida First Choice Health	$511.19
Rate for Payer: Monida Montana Health Co-op	$500.65
Rate for Payer: Monida PacificSource	$500.65

REMOVAL IMPACTED CERUMEN

Facility

$174.00

Service Code	CPT 69210
Hospital Charge Code	8069210
Hospital Revenue Code	521
Min. Negotiated Rate	$121.80
Max. Negotiated Rate	$174.00
Rate for Payer: Aetna Commercial	$165.30
Rate for Payer: Aetna Medicare	$156.60
Rate for Payer: BCBS MT CHIP	$156.60
Rate for Payer: BCBS MT Closed Plan Network	$165.30
Rate for Payer: BCBS MT HealthLink	$156.60
Rate for Payer: BCBS MT Medicare	$156.60
Rate for Payer: BCBS MT POS	$165.30
Rate for Payer: BCBS MT Traditional	$174.00
Rate for Payer: Cash Price	$156.60
Rate for Payer: Cigna Commercial	$165.30
Rate for Payer: Cigna Medicare	$156.60
Rate for Payer: Medicaid All Medicaid	$160.08
Rate for Payer: Medicare All Medicare	$121.80
Rate for Payer: Monida Allegiance	$165.30
Rate for Payer: Monida First Choice Health	$168.78
Rate for Payer: Monida Montana Health Co-op	$165.30
Rate for Payer: Monida PacificSource	$165.30

REMOVAL IMPACTED CERUMEN

Facility

$174.00

Service Code	CPT 69210
Hospital Charge Code	8069210
Hospital Revenue Code	521
Min. Negotiated Rate	$121.80
Max. Negotiated Rate	$174.00
Rate for Payer: Aetna Commercial	$165.30
Rate for Payer: Aetna Medicare	$156.60
Rate for Payer: BCBS MT CHIP	$156.60
Rate for Payer: BCBS MT Closed Plan Network	$165.30
Rate for Payer: BCBS MT HealthLink	$156.60
Rate for Payer: BCBS MT Medicare	$156.60
Rate for Payer: BCBS MT POS	$165.30
Rate for Payer: BCBS MT Traditional	$174.00
Rate for Payer: Cash Price	$156.60
Rate for Payer: Cigna Commercial	$165.30
Rate for Payer: Cigna Medicare	$156.60
Rate for Payer: Medicaid All Medicaid	$160.08
Rate for Payer: Medicare All Medicare	$121.80
Rate for Payer: Monida Allegiance	$165.30
Rate for Payer: Monida First Choice Health	$168.78
Rate for Payer: Monida Montana Health Co-op	$165.30
Rate for Payer: Monida PacificSource	$165.30

REMOVAL IMPACTED CERUMEN - IRRIGATION

Facility

$63.00

Service Code	CPT 69209
Hospital Charge Code	8069209
Hospital Revenue Code	521
Min. Negotiated Rate	$44.10
Max. Negotiated Rate	$63.00
Rate for Payer: Aetna Commercial	$59.85
Rate for Payer: Aetna Medicare	$56.70
Rate for Payer: BCBS MT CHIP	$56.70
Rate for Payer: BCBS MT Closed Plan Network	$59.85
Rate for Payer: BCBS MT HealthLink	$56.70
Rate for Payer: BCBS MT Medicare	$56.70
Rate for Payer: BCBS MT POS	$59.85
Rate for Payer: BCBS MT Traditional	$63.00
Rate for Payer: Cash Price	$56.70
Rate for Payer: Cigna Commercial	$59.85
Rate for Payer: Cigna Medicare	$56.70
Rate for Payer: Medicaid All Medicaid	$57.96
Rate for Payer: Medicare All Medicare	$44.10
Rate for Payer: Monida Allegiance	$59.85
Rate for Payer: Monida First Choice Health	$61.11
Rate for Payer: Monida Montana Health Co-op	$59.85
Rate for Payer: Monida PacificSource	$59.85

REMOVAL IMPACTED CERUMEN - IRRIGATION

Facility

$63.00

Service Code	CPT 69209
Hospital Charge Code	8069209
Hospital Revenue Code	521
Min. Negotiated Rate	$44.10
Max. Negotiated Rate	$63.00
Rate for Payer: Aetna Commercial	$59.85
Rate for Payer: Aetna Medicare	$56.70
Rate for Payer: BCBS MT CHIP	$56.70
Rate for Payer: BCBS MT Closed Plan Network	$59.85
Rate for Payer: BCBS MT HealthLink	$56.70
Rate for Payer: BCBS MT Medicare	$56.70
Rate for Payer: BCBS MT POS	$59.85
Rate for Payer: BCBS MT Traditional	$63.00
Rate for Payer: Cash Price	$56.70
Rate for Payer: Cigna Commercial	$59.85
Rate for Payer: Cigna Medicare	$56.70
Rate for Payer: Medicaid All Medicaid	$57.96
Rate for Payer: Medicare All Medicare	$44.10
Rate for Payer: Monida Allegiance	$59.85
Rate for Payer: Monida First Choice Health	$61.11
Rate for Payer: Monida Montana Health Co-op	$59.85
Rate for Payer: Monida PacificSource	$59.85

REMOVAL, NON-BIODEGRD DRUG IMPLANT 11982

Facility

$702.00

Service Code	CPT 11982
Hospital Charge Code	8011982
Hospital Revenue Code	521
Min. Negotiated Rate	$491.40
Max. Negotiated Rate	$702.00
Rate for Payer: Aetna Commercial	$666.90
Rate for Payer: Aetna Medicare	$631.80
Rate for Payer: BCBS MT CHIP	$631.80
Rate for Payer: BCBS MT Closed Plan Network	$666.90
Rate for Payer: BCBS MT HealthLink	$631.80
Rate for Payer: BCBS MT Medicare	$631.80
Rate for Payer: BCBS MT POS	$666.90
Rate for Payer: BCBS MT Traditional	$702.00
Rate for Payer: Cash Price	$631.80
Rate for Payer: Cigna Commercial	$666.90
Rate for Payer: Cigna Medicare	$631.80
Rate for Payer: Medicaid All Medicaid	$645.84
Rate for Payer: Medicare All Medicare	$491.40
Rate for Payer: Monida Allegiance	$666.90
Rate for Payer: Monida First Choice Health	$680.94
Rate for Payer: Monida Montana Health Co-op	$666.90
Rate for Payer: Monida PacificSource	$666.90

REMOVAL, NON-BIODEGRD DRUG IMPLANT 11982

Facility

$702.00

Service Code	CPT 11982
Hospital Charge Code	8011982
Hospital Revenue Code	521
Min. Negotiated Rate	$491.40
Max. Negotiated Rate	$702.00
Rate for Payer: Aetna Commercial	$666.90
Rate for Payer: Aetna Medicare	$631.80
Rate for Payer: BCBS MT CHIP	$631.80
Rate for Payer: BCBS MT Closed Plan Network	$666.90
Rate for Payer: BCBS MT HealthLink	$631.80
Rate for Payer: BCBS MT Medicare	$631.80
Rate for Payer: BCBS MT POS	$666.90
Rate for Payer: BCBS MT Traditional	$702.00
Rate for Payer: Cash Price	$631.80
Rate for Payer: Cigna Commercial	$666.90
Rate for Payer: Cigna Medicare	$631.80
Rate for Payer: Medicaid All Medicaid	$645.84
Rate for Payer: Medicare All Medicare	$491.40
Rate for Payer: Monida Allegiance	$666.90
Rate for Payer: Monida First Choice Health	$680.94
Rate for Payer: Monida Montana Health Co-op	$666.90
Rate for Payer: Monida PacificSource	$666.90

REMOVAL OF IUD 58301

Facility

$235.00

Service Code	CPT 58301
Hospital Charge Code	8058301
Hospital Revenue Code	521
Min. Negotiated Rate	$164.50
Max. Negotiated Rate	$235.00
Rate for Payer: Aetna Commercial	$223.25
Rate for Payer: Aetna Medicare	$211.50
Rate for Payer: BCBS MT CHIP	$211.50
Rate for Payer: BCBS MT Closed Plan Network	$223.25
Rate for Payer: BCBS MT HealthLink	$211.50
Rate for Payer: BCBS MT Medicare	$211.50
Rate for Payer: BCBS MT POS	$223.25
Rate for Payer: BCBS MT Traditional	$235.00
Rate for Payer: Cash Price	$211.50
Rate for Payer: Cigna Commercial	$223.25
Rate for Payer: Cigna Medicare	$211.50
Rate for Payer: Medicaid All Medicaid	$216.20
Rate for Payer: Medicare All Medicare	$164.50
Rate for Payer: Monida Allegiance	$223.25
Rate for Payer: Monida First Choice Health	$227.95
Rate for Payer: Monida Montana Health Co-op	$223.25
Rate for Payer: Monida PacificSource	$223.25

REMOVAL OF IUD 58301

Facility

$235.00

Service Code	CPT 58301
Hospital Charge Code	8058301
Hospital Revenue Code	521
Min. Negotiated Rate	$164.50
Max. Negotiated Rate	$235.00
Rate for Payer: Aetna Commercial	$223.25
Rate for Payer: Aetna Medicare	$211.50
Rate for Payer: BCBS MT CHIP	$211.50
Rate for Payer: BCBS MT Closed Plan Network	$223.25
Rate for Payer: BCBS MT HealthLink	$211.50
Rate for Payer: BCBS MT Medicare	$211.50
Rate for Payer: BCBS MT POS	$223.25
Rate for Payer: BCBS MT Traditional	$235.00
Rate for Payer: Cash Price	$211.50
Rate for Payer: Cigna Commercial	$223.25
Rate for Payer: Cigna Medicare	$211.50
Rate for Payer: Medicaid All Medicaid	$216.20
Rate for Payer: Medicare All Medicare	$164.50
Rate for Payer: Monida Allegiance	$223.25
Rate for Payer: Monida First Choice Health	$227.95
Rate for Payer: Monida Montana Health Co-op	$223.25
Rate for Payer: Monida PacificSource	$223.25

REMOVAL/REINSERT NON-BIOD IMPLANT 11983

Facility

$553.00

Service Code	CPT 11983
Hospital Charge Code	8011983
Hospital Revenue Code	521
Min. Negotiated Rate	$387.10
Max. Negotiated Rate	$553.00
Rate for Payer: Aetna Commercial	$525.35
Rate for Payer: Aetna Medicare	$497.70
Rate for Payer: BCBS MT CHIP	$497.70
Rate for Payer: BCBS MT Closed Plan Network	$525.35
Rate for Payer: BCBS MT HealthLink	$497.70
Rate for Payer: BCBS MT Medicare	$497.70
Rate for Payer: BCBS MT POS	$525.35
Rate for Payer: BCBS MT Traditional	$553.00
Rate for Payer: Cash Price	$497.70
Rate for Payer: Cigna Commercial	$525.35
Rate for Payer: Cigna Medicare	$497.70
Rate for Payer: Medicaid All Medicaid	$508.76
Rate for Payer: Medicare All Medicare	$387.10
Rate for Payer: Monida Allegiance	$525.35
Rate for Payer: Monida First Choice Health	$536.41
Rate for Payer: Monida Montana Health Co-op	$525.35
Rate for Payer: Monida PacificSource	$525.35

REMOVAL/REINSERT NON-BIOD IMPLANT 11983

Facility

$553.00

Service Code	CPT 11983
Hospital Charge Code	8011983
Hospital Revenue Code	521
Min. Negotiated Rate	$387.10
Max. Negotiated Rate	$553.00
Rate for Payer: Aetna Commercial	$525.35
Rate for Payer: Aetna Medicare	$497.70
Rate for Payer: BCBS MT CHIP	$497.70
Rate for Payer: BCBS MT Closed Plan Network	$525.35
Rate for Payer: BCBS MT HealthLink	$497.70
Rate for Payer: BCBS MT Medicare	$497.70
Rate for Payer: BCBS MT POS	$525.35
Rate for Payer: BCBS MT Traditional	$553.00
Rate for Payer: Cash Price	$497.70
Rate for Payer: Cigna Commercial	$525.35
Rate for Payer: Cigna Medicare	$497.70
Rate for Payer: Medicaid All Medicaid	$508.76
Rate for Payer: Medicare All Medicare	$387.10
Rate for Payer: Monida Allegiance	$525.35
Rate for Payer: Monida First Choice Health	$536.41
Rate for Payer: Monida Montana Health Co-op	$525.35
Rate for Payer: Monida PacificSource	$525.35

REMOVAL SKIN TAG <15 LESIONS (11200)

Facility

$225.00

Service Code	CPT 11200
Hospital Charge Code	8011200
Hospital Revenue Code	521
Min. Negotiated Rate	$157.50
Max. Negotiated Rate	$225.00
Rate for Payer: Aetna Commercial	$213.75
Rate for Payer: Aetna Medicare	$202.50
Rate for Payer: BCBS MT CHIP	$202.50
Rate for Payer: BCBS MT Closed Plan Network	$213.75
Rate for Payer: BCBS MT HealthLink	$202.50
Rate for Payer: BCBS MT Medicare	$202.50
Rate for Payer: BCBS MT POS	$213.75
Rate for Payer: BCBS MT Traditional	$225.00
Rate for Payer: Cash Price	$202.50
Rate for Payer: Cigna Commercial	$213.75
Rate for Payer: Cigna Medicare	$202.50
Rate for Payer: Medicaid All Medicaid	$207.00
Rate for Payer: Medicare All Medicare	$157.50
Rate for Payer: Monida Allegiance	$213.75
Rate for Payer: Monida First Choice Health	$218.25
Rate for Payer: Monida Montana Health Co-op	$213.75
Rate for Payer: Monida PacificSource	$213.75

REMOVAL SKIN TAG <15 LESIONS (11200)

Facility

$225.00

Service Code	CPT 11200
Hospital Charge Code	8011200
Hospital Revenue Code	521
Min. Negotiated Rate	$157.50
Max. Negotiated Rate	$225.00
Rate for Payer: Aetna Commercial	$213.75
Rate for Payer: Aetna Medicare	$202.50
Rate for Payer: BCBS MT CHIP	$202.50
Rate for Payer: BCBS MT Closed Plan Network	$213.75
Rate for Payer: BCBS MT HealthLink	$202.50
Rate for Payer: BCBS MT Medicare	$202.50
Rate for Payer: BCBS MT POS	$213.75
Rate for Payer: BCBS MT Traditional	$225.00
Rate for Payer: Cash Price	$202.50
Rate for Payer: Cigna Commercial	$213.75
Rate for Payer: Cigna Medicare	$202.50
Rate for Payer: Medicaid All Medicaid	$207.00
Rate for Payer: Medicare All Medicare	$157.50
Rate for Payer: Monida Allegiance	$213.75
Rate for Payer: Monida First Choice Health	$218.25
Rate for Payer: Monida Montana Health Co-op	$213.75
Rate for Payer: Monida PacificSource	$213.75

RENAL FUNCTION PANEL

Facility

$159.00

Service Code	CPT 80069
Hospital Charge Code	4080069
Hospital Revenue Code	300
Min. Negotiated Rate	$111.30
Max. Negotiated Rate	$159.00
Rate for Payer: Aetna Commercial	$151.05
Rate for Payer: Aetna Medicare	$143.10
Rate for Payer: BCBS MT CHIP	$143.10
Rate for Payer: BCBS MT Closed Plan Network	$151.05
Rate for Payer: BCBS MT HealthLink	$143.10
Rate for Payer: BCBS MT Medicare	$143.10
Rate for Payer: BCBS MT POS	$151.05
Rate for Payer: BCBS MT Traditional	$159.00
Rate for Payer: Cash Price	$143.10
Rate for Payer: Cigna Commercial	$151.05
Rate for Payer: Cigna Medicare	$143.10
Rate for Payer: Medicaid All Medicaid	$146.28
Rate for Payer: Medicare All Medicare	$111.30
Rate for Payer: Monida Allegiance	$151.05
Rate for Payer: Monida First Choice Health	$154.23
Rate for Payer: Monida Montana Health Co-op	$151.05
Rate for Payer: Monida PacificSource	$151.05

RENAL FUNCTION PANEL

Facility

$159.00

Service Code	CPT 80069
Hospital Charge Code	4080069
Hospital Revenue Code	300
Min. Negotiated Rate	$111.30
Max. Negotiated Rate	$159.00
Rate for Payer: Aetna Commercial	$151.05
Rate for Payer: Aetna Medicare	$143.10
Rate for Payer: BCBS MT CHIP	$143.10
Rate for Payer: BCBS MT Closed Plan Network	$151.05
Rate for Payer: BCBS MT HealthLink	$143.10
Rate for Payer: BCBS MT Medicare	$143.10
Rate for Payer: BCBS MT POS	$151.05
Rate for Payer: BCBS MT Traditional	$159.00
Rate for Payer: Cash Price	$143.10
Rate for Payer: Cigna Commercial	$151.05
Rate for Payer: Cigna Medicare	$143.10
Rate for Payer: Medicaid All Medicaid	$146.28
Rate for Payer: Medicare All Medicare	$111.30
Rate for Payer: Monida Allegiance	$151.05
Rate for Payer: Monida First Choice Health	$154.23
Rate for Payer: Monida Montana Health Co-op	$151.05
Rate for Payer: Monida PacificSource	$151.05

RENIN ACTIVITY (002006)

Facility

$68.00

Service Code	CPT 84244
Hospital Charge Code	4084244
Hospital Revenue Code	300
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

RENIN ACTIVITY (002006)

Facility

$68.00

Service Code	CPT 84244
Hospital Charge Code	4084244
Hospital Revenue Code	300
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

RESPIRATORY PANEL, NAD RVMC

Facility

$613.00

Service Code	CPT 0202U
Hospital Charge Code	4050202
Hospital Revenue Code	300
Min. Negotiated Rate	$429.10
Max. Negotiated Rate	$613.00
Rate for Payer: Aetna Commercial	$582.35
Rate for Payer: Aetna Medicare	$551.70
Rate for Payer: BCBS MT CHIP	$551.70
Rate for Payer: BCBS MT Closed Plan Network	$582.35
Rate for Payer: BCBS MT HealthLink	$551.70
Rate for Payer: BCBS MT Medicare	$551.70
Rate for Payer: BCBS MT POS	$582.35
Rate for Payer: BCBS MT Traditional	$613.00
Rate for Payer: Cash Price	$551.70
Rate for Payer: Cigna Commercial	$582.35
Rate for Payer: Cigna Medicare	$551.70
Rate for Payer: Medicaid All Medicaid	$563.96
Rate for Payer: Medicare All Medicare	$429.10
Rate for Payer: Monida Allegiance	$582.35
Rate for Payer: Monida First Choice Health	$594.61
Rate for Payer: Monida Montana Health Co-op	$582.35
Rate for Payer: Monida PacificSource	$582.35

RESPIRATORY PANEL, NAD RVMC

Facility

$613.00

Service Code	CPT 0202U
Hospital Charge Code	4050202
Hospital Revenue Code	300
Min. Negotiated Rate	$429.10
Max. Negotiated Rate	$613.00
Rate for Payer: Aetna Commercial	$582.35
Rate for Payer: Aetna Medicare	$551.70
Rate for Payer: BCBS MT CHIP	$551.70
Rate for Payer: BCBS MT Closed Plan Network	$582.35
Rate for Payer: BCBS MT HealthLink	$551.70
Rate for Payer: BCBS MT Medicare	$551.70
Rate for Payer: BCBS MT POS	$582.35
Rate for Payer: BCBS MT Traditional	$613.00
Rate for Payer: Cash Price	$551.70
Rate for Payer: Cigna Commercial	$582.35
Rate for Payer: Cigna Medicare	$551.70
Rate for Payer: Medicaid All Medicaid	$563.96
Rate for Payer: Medicare All Medicare	$429.10
Rate for Payer: Monida Allegiance	$582.35
Rate for Payer: Monida First Choice Health	$594.61
Rate for Payer: Monida Montana Health Co-op	$582.35
Rate for Payer: Monida PacificSource	$582.35

RESPITE CARE

Facility

$445.00

Hospital Charge Code	800001
Hospital Revenue Code	120
Min. Negotiated Rate	$311.50
Max. Negotiated Rate	$445.00
Rate for Payer: Aetna Commercial	$422.75
Rate for Payer: Aetna Medicare	$400.50
Rate for Payer: BCBS MT CHIP	$400.50
Rate for Payer: BCBS MT Closed Plan Network	$422.75
Rate for Payer: BCBS MT HealthLink	$400.50
Rate for Payer: BCBS MT Medicare	$400.50
Rate for Payer: BCBS MT POS	$422.75
Rate for Payer: BCBS MT Traditional	$445.00
Rate for Payer: Cash Price	$400.50
Rate for Payer: Cigna Commercial	$422.75
Rate for Payer: Cigna Medicare	$400.50
Rate for Payer: Medicaid All Medicaid	$409.40
Rate for Payer: Medicare All Medicare	$311.50
Rate for Payer: Monida Allegiance	$422.75
Rate for Payer: Monida First Choice Health	$431.65
Rate for Payer: Monida Montana Health Co-op	$422.75
Rate for Payer: Monida PacificSource	$422.75

RESUSCITATOR INFANT

Facility

$152.00

Hospital Charge Code	80030011
Hospital Revenue Code	270
Min. Negotiated Rate	$106.40
Max. Negotiated Rate	$152.00
Rate for Payer: Aetna Commercial	$144.40
Rate for Payer: Aetna Medicare	$136.80
Rate for Payer: BCBS MT CHIP	$136.80
Rate for Payer: BCBS MT Closed Plan Network	$144.40
Rate for Payer: BCBS MT HealthLink	$136.80
Rate for Payer: BCBS MT Medicare	$136.80
Rate for Payer: BCBS MT POS	$144.40
Rate for Payer: BCBS MT Traditional	$152.00
Rate for Payer: Cash Price	$136.80
Rate for Payer: Cigna Commercial	$144.40
Rate for Payer: Cigna Medicare	$136.80
Rate for Payer: Medicaid All Medicaid	$139.84
Rate for Payer: Medicare All Medicare	$106.40
Rate for Payer: Monida Allegiance	$144.40
Rate for Payer: Monida First Choice Health	$147.44
Rate for Payer: Monida Montana Health Co-op	$144.40
Rate for Payer: Monida PacificSource	$144.40

RESUSCITATOR INFANT

Facility

$152.00

Hospital Charge Code	80030011
Hospital Revenue Code	270
Min. Negotiated Rate	$106.40
Max. Negotiated Rate	$152.00
Rate for Payer: Aetna Commercial	$144.40
Rate for Payer: Aetna Medicare	$136.80
Rate for Payer: BCBS MT CHIP	$136.80
Rate for Payer: BCBS MT Closed Plan Network	$144.40
Rate for Payer: BCBS MT HealthLink	$136.80
Rate for Payer: BCBS MT Medicare	$136.80
Rate for Payer: BCBS MT POS	$144.40
Rate for Payer: BCBS MT Traditional	$152.00
Rate for Payer: Cash Price	$136.80
Rate for Payer: Cigna Commercial	$144.40
Rate for Payer: Cigna Medicare	$136.80
Rate for Payer: Medicaid All Medicaid	$139.84
Rate for Payer: Medicare All Medicare	$106.40
Rate for Payer: Monida Allegiance	$144.40
Rate for Payer: Monida First Choice Health	$147.44
Rate for Payer: Monida Montana Health Co-op	$144.40
Rate for Payer: Monida PacificSource	$144.40

RETICULOCYTE COUNT (005280)

Facility

$13.00

Service Code	CPT 85045
Hospital Charge Code	4085046
Hospital Revenue Code	300
Min. Negotiated Rate	$9.10
Max. Negotiated Rate	$13.00
Rate for Payer: Aetna Commercial	$12.35
Rate for Payer: Aetna Medicare	$11.70
Rate for Payer: BCBS MT CHIP	$11.70
Rate for Payer: BCBS MT Closed Plan Network	$12.35
Rate for Payer: BCBS MT HealthLink	$11.70
Rate for Payer: BCBS MT Medicare	$11.70
Rate for Payer: BCBS MT POS	$12.35
Rate for Payer: BCBS MT Traditional	$13.00
Rate for Payer: Cash Price	$11.70
Rate for Payer: Cigna Commercial	$12.35
Rate for Payer: Cigna Medicare	$11.70
Rate for Payer: Medicaid All Medicaid	$11.96
Rate for Payer: Medicare All Medicare	$9.10
Rate for Payer: Monida Allegiance	$12.35
Rate for Payer: Monida First Choice Health	$12.61
Rate for Payer: Monida Montana Health Co-op	$12.35
Rate for Payer: Monida PacificSource	$12.35

RETICULOCYTE COUNT (005280)

Facility

$13.00

Service Code	CPT 85045
Hospital Charge Code	4085046
Hospital Revenue Code	300
Min. Negotiated Rate	$9.10
Max. Negotiated Rate	$13.00
Rate for Payer: Aetna Commercial	$12.35
Rate for Payer: Aetna Medicare	$11.70
Rate for Payer: BCBS MT CHIP	$11.70
Rate for Payer: BCBS MT Closed Plan Network	$12.35
Rate for Payer: BCBS MT HealthLink	$11.70
Rate for Payer: BCBS MT Medicare	$11.70
Rate for Payer: BCBS MT POS	$12.35
Rate for Payer: BCBS MT Traditional	$13.00
Rate for Payer: Cash Price	$11.70
Rate for Payer: Cigna Commercial	$12.35
Rate for Payer: Cigna Medicare	$11.70
Rate for Payer: Medicaid All Medicaid	$11.96
Rate for Payer: Medicare All Medicare	$9.10
Rate for Payer: Monida Allegiance	$12.35
Rate for Payer: Monida First Choice Health	$12.61
Rate for Payer: Monida Montana Health Co-op	$12.35
Rate for Payer: Monida PacificSource	$12.35

Know your out-of-pocket cost for care.

All Charges