Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

SAM SPLINT 4.25'X36' FLAT

Facility

$46.00

Hospital Charge Code	2893496
Hospital Revenue Code	290
Min. Negotiated Rate	$32.20
Max. Negotiated Rate	$46.00
Rate for Payer: Aetna Commercial	$43.70
Rate for Payer: Aetna Medicare	$41.40
Rate for Payer: BCBS MT CHIP	$41.40
Rate for Payer: BCBS MT Closed Plan Network	$43.70
Rate for Payer: BCBS MT HealthLink	$41.40
Rate for Payer: BCBS MT Medicare	$41.40
Rate for Payer: BCBS MT POS	$43.70
Rate for Payer: BCBS MT Traditional	$46.00
Rate for Payer: Cash Price	$41.40
Rate for Payer: Cigna Commercial	$43.70
Rate for Payer: Cigna Medicare	$41.40
Rate for Payer: Medicaid All Medicaid	$42.32
Rate for Payer: Medicare All Medicare	$32.20
Rate for Payer: Monida Allegiance	$43.70
Rate for Payer: Monida First Choice Health	$44.62
Rate for Payer: Monida Montana Health Co-op	$43.70
Rate for Payer: Monida PacificSource	$43.70

SARS-COV-2, AG BINAX

Facility

$155.00

Service Code	CPT 87426
Hospital Charge Code	4087426
Hospital Revenue Code	300
Min. Negotiated Rate	$108.50
Max. Negotiated Rate	$155.00
Rate for Payer: Aetna Commercial	$147.25
Rate for Payer: Aetna Medicare	$139.50
Rate for Payer: BCBS MT CHIP	$139.50
Rate for Payer: BCBS MT Closed Plan Network	$147.25
Rate for Payer: BCBS MT HealthLink	$139.50
Rate for Payer: BCBS MT Medicare	$139.50
Rate for Payer: BCBS MT POS	$147.25
Rate for Payer: BCBS MT Traditional	$155.00
Rate for Payer: Cash Price	$139.50
Rate for Payer: Cigna Commercial	$147.25
Rate for Payer: Cigna Medicare	$139.50
Rate for Payer: Medicaid All Medicaid	$142.60
Rate for Payer: Medicare All Medicare	$108.50
Rate for Payer: Monida Allegiance	$147.25
Rate for Payer: Monida First Choice Health	$150.35
Rate for Payer: Monida Montana Health Co-op	$147.25
Rate for Payer: Monida PacificSource	$147.25

SARS-COV-2, AG BINAX

Facility

$155.00

Service Code	CPT 87426
Hospital Charge Code	4087426
Hospital Revenue Code	300
Min. Negotiated Rate	$108.50
Max. Negotiated Rate	$155.00
Rate for Payer: Aetna Commercial	$147.25
Rate for Payer: Aetna Medicare	$139.50
Rate for Payer: BCBS MT CHIP	$139.50
Rate for Payer: BCBS MT Closed Plan Network	$147.25
Rate for Payer: BCBS MT HealthLink	$139.50
Rate for Payer: BCBS MT Medicare	$139.50
Rate for Payer: BCBS MT POS	$147.25
Rate for Payer: BCBS MT Traditional	$155.00
Rate for Payer: Cash Price	$139.50
Rate for Payer: Cigna Commercial	$147.25
Rate for Payer: Cigna Medicare	$139.50
Rate for Payer: Medicaid All Medicaid	$142.60
Rate for Payer: Medicare All Medicare	$108.50
Rate for Payer: Monida Allegiance	$147.25
Rate for Payer: Monida First Choice Health	$150.35
Rate for Payer: Monida Montana Health Co-op	$147.25
Rate for Payer: Monida PacificSource	$147.25

SARS-COV-2/FLU A/FLU B/RSV, RT-PCR

Facility

$552.00

Service Code	CPT 87637
Hospital Charge Code	4050241
Hospital Revenue Code	300
Min. Negotiated Rate	$386.40
Max. Negotiated Rate	$552.00
Rate for Payer: Aetna Commercial	$524.40
Rate for Payer: Aetna Medicare	$496.80
Rate for Payer: BCBS MT CHIP	$496.80
Rate for Payer: BCBS MT Closed Plan Network	$524.40
Rate for Payer: BCBS MT HealthLink	$496.80
Rate for Payer: BCBS MT Medicare	$496.80
Rate for Payer: BCBS MT POS	$524.40
Rate for Payer: BCBS MT Traditional	$552.00
Rate for Payer: Cash Price	$496.80
Rate for Payer: Cigna Commercial	$524.40
Rate for Payer: Cigna Medicare	$496.80
Rate for Payer: Medicaid All Medicaid	$507.84
Rate for Payer: Medicare All Medicare	$386.40
Rate for Payer: Monida Allegiance	$524.40
Rate for Payer: Monida First Choice Health	$535.44
Rate for Payer: Monida Montana Health Co-op	$524.40
Rate for Payer: Monida PacificSource	$524.40

SARS-COV-2/FLU A/FLU B/RSV, RT-PCR

Facility

$552.00

Service Code	CPT 87637
Hospital Charge Code	4050241
Hospital Revenue Code	300
Min. Negotiated Rate	$386.40
Max. Negotiated Rate	$552.00
Rate for Payer: Aetna Commercial	$524.40
Rate for Payer: Aetna Medicare	$496.80
Rate for Payer: BCBS MT CHIP	$496.80
Rate for Payer: BCBS MT Closed Plan Network	$524.40
Rate for Payer: BCBS MT HealthLink	$496.80
Rate for Payer: BCBS MT Medicare	$496.80
Rate for Payer: BCBS MT POS	$524.40
Rate for Payer: BCBS MT Traditional	$552.00
Rate for Payer: Cash Price	$496.80
Rate for Payer: Cigna Commercial	$524.40
Rate for Payer: Cigna Medicare	$496.80
Rate for Payer: Medicaid All Medicaid	$507.84
Rate for Payer: Medicare All Medicare	$386.40
Rate for Payer: Monida Allegiance	$524.40
Rate for Payer: Monida First Choice Health	$535.44
Rate for Payer: Monida Montana Health Co-op	$524.40
Rate for Payer: Monida PacificSource	$524.40

SARS-COV-2/FLU A/FLU B, RT-PCR

Facility

$265.00

Service Code	CPT 87636
Hospital Charge Code	4050240
Hospital Revenue Code	300
Min. Negotiated Rate	$185.50
Max. Negotiated Rate	$265.00
Rate for Payer: Aetna Commercial	$251.75
Rate for Payer: Aetna Medicare	$238.50
Rate for Payer: BCBS MT CHIP	$238.50
Rate for Payer: BCBS MT Closed Plan Network	$251.75
Rate for Payer: BCBS MT HealthLink	$238.50
Rate for Payer: BCBS MT Medicare	$238.50
Rate for Payer: BCBS MT POS	$251.75
Rate for Payer: BCBS MT Traditional	$265.00
Rate for Payer: Cash Price	$238.50
Rate for Payer: Cigna Commercial	$251.75
Rate for Payer: Cigna Medicare	$238.50
Rate for Payer: Medicaid All Medicaid	$243.80
Rate for Payer: Medicare All Medicare	$185.50
Rate for Payer: Monida Allegiance	$251.75
Rate for Payer: Monida First Choice Health	$257.05
Rate for Payer: Monida Montana Health Co-op	$251.75
Rate for Payer: Monida PacificSource	$251.75

SARS-COV-2/FLU A/FLU B, RT-PCR

Facility

$265.00

Service Code	CPT 87636
Hospital Charge Code	4050240
Hospital Revenue Code	300
Min. Negotiated Rate	$185.50
Max. Negotiated Rate	$265.00
Rate for Payer: Aetna Commercial	$251.75
Rate for Payer: Aetna Medicare	$238.50
Rate for Payer: BCBS MT CHIP	$238.50
Rate for Payer: BCBS MT Closed Plan Network	$251.75
Rate for Payer: BCBS MT HealthLink	$238.50
Rate for Payer: BCBS MT Medicare	$238.50
Rate for Payer: BCBS MT POS	$251.75
Rate for Payer: BCBS MT Traditional	$265.00
Rate for Payer: Cash Price	$238.50
Rate for Payer: Cigna Commercial	$251.75
Rate for Payer: Cigna Medicare	$238.50
Rate for Payer: Medicaid All Medicaid	$243.80
Rate for Payer: Medicare All Medicare	$185.50
Rate for Payer: Monida Allegiance	$251.75
Rate for Payer: Monida First Choice Health	$257.05
Rate for Payer: Monida Montana Health Co-op	$251.75
Rate for Payer: Monida PacificSource	$251.75

SARS-COV-2, RT-PCR

Facility

$215.00

Service Code	CPT 87635
Hospital Charge Code	4087635
Hospital Revenue Code	300
Min. Negotiated Rate	$150.50
Max. Negotiated Rate	$215.00
Rate for Payer: Aetna Commercial	$204.25
Rate for Payer: Aetna Medicare	$193.50
Rate for Payer: BCBS MT CHIP	$193.50
Rate for Payer: BCBS MT Closed Plan Network	$204.25
Rate for Payer: BCBS MT HealthLink	$193.50
Rate for Payer: BCBS MT Medicare	$193.50
Rate for Payer: BCBS MT POS	$204.25
Rate for Payer: BCBS MT Traditional	$215.00
Rate for Payer: Cash Price	$193.50
Rate for Payer: Cigna Commercial	$204.25
Rate for Payer: Cigna Medicare	$193.50
Rate for Payer: Medicaid All Medicaid	$197.80
Rate for Payer: Medicare All Medicare	$150.50
Rate for Payer: Monida Allegiance	$204.25
Rate for Payer: Monida First Choice Health	$208.55
Rate for Payer: Monida Montana Health Co-op	$204.25
Rate for Payer: Monida PacificSource	$204.25

SARS-COV-2, RT-PCR

Facility

$215.00

Service Code	CPT 87635
Hospital Charge Code	4087635
Hospital Revenue Code	300
Min. Negotiated Rate	$150.50
Max. Negotiated Rate	$215.00
Rate for Payer: Aetna Commercial	$204.25
Rate for Payer: Aetna Medicare	$193.50
Rate for Payer: BCBS MT CHIP	$193.50
Rate for Payer: BCBS MT Closed Plan Network	$204.25
Rate for Payer: BCBS MT HealthLink	$193.50
Rate for Payer: BCBS MT Medicare	$193.50
Rate for Payer: BCBS MT POS	$204.25
Rate for Payer: BCBS MT Traditional	$215.00
Rate for Payer: Cash Price	$193.50
Rate for Payer: Cigna Commercial	$204.25
Rate for Payer: Cigna Medicare	$193.50
Rate for Payer: Medicaid All Medicaid	$197.80
Rate for Payer: Medicare All Medicare	$150.50
Rate for Payer: Monida Allegiance	$204.25
Rate for Payer: Monida First Choice Health	$208.55
Rate for Payer: Monida Montana Health Co-op	$204.25
Rate for Payer: Monida PacificSource	$204.25

SARS-COV-2 SEMI-QUANT IGG AB (164055)

Facility

$111.00

Service Code	CPT 86769
Hospital Charge Code	4086769
Hospital Revenue Code	300
Min. Negotiated Rate	$77.70
Max. Negotiated Rate	$111.00
Rate for Payer: Aetna Commercial	$105.45
Rate for Payer: Aetna Medicare	$99.90
Rate for Payer: BCBS MT CHIP	$99.90
Rate for Payer: BCBS MT Closed Plan Network	$105.45
Rate for Payer: BCBS MT HealthLink	$99.90
Rate for Payer: BCBS MT Medicare	$99.90
Rate for Payer: BCBS MT POS	$105.45
Rate for Payer: BCBS MT Traditional	$111.00
Rate for Payer: Cash Price	$99.90
Rate for Payer: Cigna Commercial	$105.45
Rate for Payer: Cigna Medicare	$99.90
Rate for Payer: Medicaid All Medicaid	$102.12
Rate for Payer: Medicare All Medicare	$77.70
Rate for Payer: Monida Allegiance	$105.45
Rate for Payer: Monida First Choice Health	$107.67
Rate for Payer: Monida Montana Health Co-op	$105.45
Rate for Payer: Monida PacificSource	$105.45

SARS-COV-2 SEMI-QUANT IGG AB (164055)

Facility

$111.00

Service Code	CPT 86769
Hospital Charge Code	4086769
Hospital Revenue Code	300
Min. Negotiated Rate	$77.70
Max. Negotiated Rate	$111.00
Rate for Payer: Aetna Commercial	$105.45
Rate for Payer: Aetna Medicare	$99.90
Rate for Payer: BCBS MT CHIP	$99.90
Rate for Payer: BCBS MT Closed Plan Network	$105.45
Rate for Payer: BCBS MT HealthLink	$99.90
Rate for Payer: BCBS MT Medicare	$99.90
Rate for Payer: BCBS MT POS	$105.45
Rate for Payer: BCBS MT Traditional	$111.00
Rate for Payer: Cash Price	$99.90
Rate for Payer: Cigna Commercial	$105.45
Rate for Payer: Cigna Medicare	$99.90
Rate for Payer: Medicaid All Medicaid	$102.12
Rate for Payer: Medicare All Medicare	$77.70
Rate for Payer: Monida Allegiance	$105.45
Rate for Payer: Monida First Choice Health	$107.67
Rate for Payer: Monida Montana Health Co-op	$105.45
Rate for Payer: Monida PacificSource	$105.45

SARS-COV-2, TRAVEL

Facility

$111.00

Service Code	CPT 87635
Hospital Charge Code	4000076
Hospital Revenue Code	300
Min. Negotiated Rate	$77.70
Max. Negotiated Rate	$111.00
Rate for Payer: Aetna Commercial	$105.45
Rate for Payer: Aetna Medicare	$99.90
Rate for Payer: BCBS MT CHIP	$99.90
Rate for Payer: BCBS MT Closed Plan Network	$105.45
Rate for Payer: BCBS MT HealthLink	$99.90
Rate for Payer: BCBS MT Medicare	$99.90
Rate for Payer: BCBS MT POS	$105.45
Rate for Payer: BCBS MT Traditional	$111.00
Rate for Payer: Cash Price	$99.90
Rate for Payer: Cigna Commercial	$105.45
Rate for Payer: Cigna Medicare	$99.90
Rate for Payer: Medicaid All Medicaid	$102.12
Rate for Payer: Medicare All Medicare	$77.70
Rate for Payer: Monida Allegiance	$105.45
Rate for Payer: Monida First Choice Health	$107.67
Rate for Payer: Monida Montana Health Co-op	$105.45
Rate for Payer: Monida PacificSource	$105.45

SARS-COV-2, TRAVEL

Facility

$111.00

Service Code	CPT 87635
Hospital Charge Code	4000076
Hospital Revenue Code	300
Min. Negotiated Rate	$77.70
Max. Negotiated Rate	$111.00
Rate for Payer: Aetna Commercial	$105.45
Rate for Payer: Aetna Medicare	$99.90
Rate for Payer: BCBS MT CHIP	$99.90
Rate for Payer: BCBS MT Closed Plan Network	$105.45
Rate for Payer: BCBS MT HealthLink	$99.90
Rate for Payer: BCBS MT Medicare	$99.90
Rate for Payer: BCBS MT POS	$105.45
Rate for Payer: BCBS MT Traditional	$111.00
Rate for Payer: Cash Price	$99.90
Rate for Payer: Cigna Commercial	$105.45
Rate for Payer: Cigna Medicare	$99.90
Rate for Payer: Medicaid All Medicaid	$102.12
Rate for Payer: Medicare All Medicare	$77.70
Rate for Payer: Monida Allegiance	$105.45
Rate for Payer: Monida First Choice Health	$107.67
Rate for Payer: Monida Montana Health Co-op	$105.45
Rate for Payer: Monida PacificSource	$105.45

SB/NH ADMISSION HIGH LEVEL-50 MIN(99306)

Facility

$368.00

Service Code	CPT 99306
Hospital Charge Code	799306
Hospital Revenue Code	521
Min. Negotiated Rate	$257.60
Max. Negotiated Rate	$368.00
Rate for Payer: Aetna Commercial	$349.60
Rate for Payer: Aetna Medicare	$331.20
Rate for Payer: BCBS MT CHIP	$331.20
Rate for Payer: BCBS MT Closed Plan Network	$349.60
Rate for Payer: BCBS MT HealthLink	$331.20
Rate for Payer: BCBS MT Medicare	$331.20
Rate for Payer: BCBS MT POS	$349.60
Rate for Payer: BCBS MT Traditional	$368.00
Rate for Payer: Cash Price	$331.20
Rate for Payer: Cigna Commercial	$349.60
Rate for Payer: Cigna Medicare	$331.20
Rate for Payer: Medicaid All Medicaid	$338.56
Rate for Payer: Medicare All Medicare	$257.60
Rate for Payer: Monida Allegiance	$349.60
Rate for Payer: Monida First Choice Health	$356.96
Rate for Payer: Monida Montana Health Co-op	$349.60
Rate for Payer: Monida PacificSource	$349.60

SB/NH ADMISSION HIGH LEVEL-50 MIN(99306)

Facility

$368.00

Service Code	CPT 99306
Hospital Charge Code	799306
Hospital Revenue Code	521
Min. Negotiated Rate	$257.60
Max. Negotiated Rate	$368.00
Rate for Payer: Aetna Commercial	$349.60
Rate for Payer: Aetna Medicare	$331.20
Rate for Payer: BCBS MT CHIP	$331.20
Rate for Payer: BCBS MT Closed Plan Network	$349.60
Rate for Payer: BCBS MT HealthLink	$331.20
Rate for Payer: BCBS MT Medicare	$331.20
Rate for Payer: BCBS MT POS	$349.60
Rate for Payer: BCBS MT Traditional	$368.00
Rate for Payer: Cash Price	$331.20
Rate for Payer: Cigna Commercial	$349.60
Rate for Payer: Cigna Medicare	$331.20
Rate for Payer: Medicaid All Medicaid	$338.56
Rate for Payer: Medicare All Medicare	$257.60
Rate for Payer: Monida Allegiance	$349.60
Rate for Payer: Monida First Choice Health	$356.96
Rate for Payer: Monida Montana Health Co-op	$349.60
Rate for Payer: Monida PacificSource	$349.60

SB/NH ADMISSION LOW LEVEL-25 MIN (99304)

Facility

$206.00

Service Code	CPT 99304
Hospital Charge Code	799304
Hospital Revenue Code	521
Min. Negotiated Rate	$144.20
Max. Negotiated Rate	$206.00
Rate for Payer: Aetna Commercial	$195.70
Rate for Payer: Aetna Medicare	$185.40
Rate for Payer: BCBS MT CHIP	$185.40
Rate for Payer: BCBS MT Closed Plan Network	$195.70
Rate for Payer: BCBS MT HealthLink	$185.40
Rate for Payer: BCBS MT Medicare	$185.40
Rate for Payer: BCBS MT POS	$195.70
Rate for Payer: BCBS MT Traditional	$206.00
Rate for Payer: Cash Price	$185.40
Rate for Payer: Cigna Commercial	$195.70
Rate for Payer: Cigna Medicare	$185.40
Rate for Payer: Medicaid All Medicaid	$189.52
Rate for Payer: Medicare All Medicare	$144.20
Rate for Payer: Monida Allegiance	$195.70
Rate for Payer: Monida First Choice Health	$199.82
Rate for Payer: Monida Montana Health Co-op	$195.70
Rate for Payer: Monida PacificSource	$195.70

SB/NH ADMISSION LOW LEVEL-25 MIN (99304)

Facility

$206.00

Service Code	CPT 99304
Hospital Charge Code	799304
Hospital Revenue Code	521
Min. Negotiated Rate	$144.20
Max. Negotiated Rate	$206.00
Rate for Payer: Aetna Commercial	$195.70
Rate for Payer: Aetna Medicare	$185.40
Rate for Payer: BCBS MT CHIP	$185.40
Rate for Payer: BCBS MT Closed Plan Network	$195.70
Rate for Payer: BCBS MT HealthLink	$185.40
Rate for Payer: BCBS MT Medicare	$185.40
Rate for Payer: BCBS MT POS	$195.70
Rate for Payer: BCBS MT Traditional	$206.00
Rate for Payer: Cash Price	$185.40
Rate for Payer: Cigna Commercial	$195.70
Rate for Payer: Cigna Medicare	$185.40
Rate for Payer: Medicaid All Medicaid	$189.52
Rate for Payer: Medicare All Medicare	$144.20
Rate for Payer: Monida Allegiance	$195.70
Rate for Payer: Monida First Choice Health	$199.82
Rate for Payer: Monida Montana Health Co-op	$195.70
Rate for Payer: Monida PacificSource	$195.70

SB/NH ADMISSION MODERATE-35 MIN (99305)

Facility

$289.00

Service Code	CPT 99305
Hospital Charge Code	799305
Hospital Revenue Code	521
Min. Negotiated Rate	$202.30
Max. Negotiated Rate	$289.00
Rate for Payer: Aetna Commercial	$274.55
Rate for Payer: Aetna Medicare	$260.10
Rate for Payer: BCBS MT CHIP	$260.10
Rate for Payer: BCBS MT Closed Plan Network	$274.55
Rate for Payer: BCBS MT HealthLink	$260.10
Rate for Payer: BCBS MT Medicare	$260.10
Rate for Payer: BCBS MT POS	$274.55
Rate for Payer: BCBS MT Traditional	$289.00
Rate for Payer: Cash Price	$260.10
Rate for Payer: Cigna Commercial	$274.55
Rate for Payer: Cigna Medicare	$260.10
Rate for Payer: Medicaid All Medicaid	$265.88
Rate for Payer: Medicare All Medicare	$202.30
Rate for Payer: Monida Allegiance	$274.55
Rate for Payer: Monida First Choice Health	$280.33
Rate for Payer: Monida Montana Health Co-op	$274.55
Rate for Payer: Monida PacificSource	$274.55

SB/NH ADMISSION MODERATE-35 MIN (99305)

Facility

$289.00

Service Code	CPT 99305
Hospital Charge Code	799305
Hospital Revenue Code	521
Min. Negotiated Rate	$202.30
Max. Negotiated Rate	$289.00
Rate for Payer: Aetna Commercial	$274.55
Rate for Payer: Aetna Medicare	$260.10
Rate for Payer: BCBS MT CHIP	$260.10
Rate for Payer: BCBS MT Closed Plan Network	$274.55
Rate for Payer: BCBS MT HealthLink	$260.10
Rate for Payer: BCBS MT Medicare	$260.10
Rate for Payer: BCBS MT POS	$274.55
Rate for Payer: BCBS MT Traditional	$289.00
Rate for Payer: Cash Price	$260.10
Rate for Payer: Cigna Commercial	$274.55
Rate for Payer: Cigna Medicare	$260.10
Rate for Payer: Medicaid All Medicaid	$265.88
Rate for Payer: Medicare All Medicare	$202.30
Rate for Payer: Monida Allegiance	$274.55
Rate for Payer: Monida First Choice Health	$280.33
Rate for Payer: Monida Montana Health Co-op	$274.55
Rate for Payer: Monida PacificSource	$274.55

SB/NH ANNUAL ASSESSMENT (99318)

Facility

$212.00

Service Code	CPT 99318
Hospital Charge Code	799318
Hospital Revenue Code	521
Min. Negotiated Rate	$148.40
Max. Negotiated Rate	$212.00
Rate for Payer: Aetna Commercial	$201.40
Rate for Payer: Aetna Medicare	$190.80
Rate for Payer: BCBS MT CHIP	$190.80
Rate for Payer: BCBS MT Closed Plan Network	$201.40
Rate for Payer: BCBS MT HealthLink	$190.80
Rate for Payer: BCBS MT Medicare	$190.80
Rate for Payer: BCBS MT POS	$201.40
Rate for Payer: BCBS MT Traditional	$212.00
Rate for Payer: Cash Price	$190.80
Rate for Payer: Cigna Commercial	$201.40
Rate for Payer: Cigna Medicare	$190.80
Rate for Payer: Medicaid All Medicaid	$195.04
Rate for Payer: Medicare All Medicare	$148.40
Rate for Payer: Monida Allegiance	$201.40
Rate for Payer: Monida First Choice Health	$205.64
Rate for Payer: Monida Montana Health Co-op	$201.40
Rate for Payer: Monida PacificSource	$201.40

SB/NH ANNUAL ASSESSMENT (99318)

Facility

$212.00

Service Code	CPT 99318
Hospital Charge Code	799318
Hospital Revenue Code	521
Min. Negotiated Rate	$148.40
Max. Negotiated Rate	$212.00
Rate for Payer: Aetna Commercial	$201.40
Rate for Payer: Aetna Medicare	$190.80
Rate for Payer: BCBS MT CHIP	$190.80
Rate for Payer: BCBS MT Closed Plan Network	$201.40
Rate for Payer: BCBS MT HealthLink	$190.80
Rate for Payer: BCBS MT Medicare	$190.80
Rate for Payer: BCBS MT POS	$201.40
Rate for Payer: BCBS MT Traditional	$212.00
Rate for Payer: Cash Price	$190.80
Rate for Payer: Cigna Commercial	$201.40
Rate for Payer: Cigna Medicare	$190.80
Rate for Payer: Medicaid All Medicaid	$195.04
Rate for Payer: Medicare All Medicare	$148.40
Rate for Payer: Monida Allegiance	$201.40
Rate for Payer: Monida First Choice Health	$205.64
Rate for Payer: Monida Montana Health Co-op	$201.40
Rate for Payer: Monida PacificSource	$201.40

SB/NH DISCHARGE 30 MIN (99315)

Facility

$161.00

Service Code	CPT 99315
Hospital Charge Code	799315
Hospital Revenue Code	521
Min. Negotiated Rate	$112.70
Max. Negotiated Rate	$161.00
Rate for Payer: Aetna Commercial	$152.95
Rate for Payer: Aetna Medicare	$144.90
Rate for Payer: BCBS MT CHIP	$144.90
Rate for Payer: BCBS MT Closed Plan Network	$152.95
Rate for Payer: BCBS MT HealthLink	$144.90
Rate for Payer: BCBS MT Medicare	$144.90
Rate for Payer: BCBS MT POS	$152.95
Rate for Payer: BCBS MT Traditional	$161.00
Rate for Payer: Cash Price	$144.90
Rate for Payer: Cigna Commercial	$152.95
Rate for Payer: Cigna Medicare	$144.90
Rate for Payer: Medicaid All Medicaid	$148.12
Rate for Payer: Medicare All Medicare	$112.70
Rate for Payer: Monida Allegiance	$152.95
Rate for Payer: Monida First Choice Health	$156.17
Rate for Payer: Monida Montana Health Co-op	$152.95
Rate for Payer: Monida PacificSource	$152.95

SB/NH DISCHARGE 30 MIN (99315)

Facility

$161.00

Service Code	CPT 99315
Hospital Charge Code	799315
Hospital Revenue Code	521
Min. Negotiated Rate	$112.70
Max. Negotiated Rate	$161.00
Rate for Payer: Aetna Commercial	$152.95
Rate for Payer: Aetna Medicare	$144.90
Rate for Payer: BCBS MT CHIP	$144.90
Rate for Payer: BCBS MT Closed Plan Network	$152.95
Rate for Payer: BCBS MT HealthLink	$144.90
Rate for Payer: BCBS MT Medicare	$144.90
Rate for Payer: BCBS MT POS	$152.95
Rate for Payer: BCBS MT Traditional	$161.00
Rate for Payer: Cash Price	$144.90
Rate for Payer: Cigna Commercial	$152.95
Rate for Payer: Cigna Medicare	$144.90
Rate for Payer: Medicaid All Medicaid	$148.12
Rate for Payer: Medicare All Medicare	$112.70
Rate for Payer: Monida Allegiance	$152.95
Rate for Payer: Monida First Choice Health	$156.17
Rate for Payer: Monida Montana Health Co-op	$152.95
Rate for Payer: Monida PacificSource	$152.95

SB/NH DISCHARGE >30 MIN (99316)

Facility

$234.00

Service Code	CPT 99316
Hospital Charge Code	799316
Hospital Revenue Code	521
Min. Negotiated Rate	$163.80
Max. Negotiated Rate	$234.00
Rate for Payer: Aetna Commercial	$222.30
Rate for Payer: Aetna Medicare	$210.60
Rate for Payer: BCBS MT CHIP	$210.60
Rate for Payer: BCBS MT Closed Plan Network	$222.30
Rate for Payer: BCBS MT HealthLink	$210.60
Rate for Payer: BCBS MT Medicare	$210.60
Rate for Payer: BCBS MT POS	$222.30
Rate for Payer: BCBS MT Traditional	$234.00
Rate for Payer: Cash Price	$210.60
Rate for Payer: Cigna Commercial	$222.30
Rate for Payer: Cigna Medicare	$210.60
Rate for Payer: Medicaid All Medicaid	$215.28
Rate for Payer: Medicare All Medicare	$163.80
Rate for Payer: Monida Allegiance	$222.30
Rate for Payer: Monida First Choice Health	$226.98
Rate for Payer: Monida Montana Health Co-op	$222.30
Rate for Payer: Monida PacificSource	$222.30

SB/NH DISCHARGE >30 MIN (99316)

Facility

$234.00

Service Code	CPT 99316
Hospital Charge Code	799316
Hospital Revenue Code	521
Min. Negotiated Rate	$163.80
Max. Negotiated Rate	$234.00
Rate for Payer: Aetna Commercial	$222.30
Rate for Payer: Aetna Medicare	$210.60
Rate for Payer: BCBS MT CHIP	$210.60
Rate for Payer: BCBS MT Closed Plan Network	$222.30
Rate for Payer: BCBS MT HealthLink	$210.60
Rate for Payer: BCBS MT Medicare	$210.60
Rate for Payer: BCBS MT POS	$222.30
Rate for Payer: BCBS MT Traditional	$234.00
Rate for Payer: Cash Price	$210.60
Rate for Payer: Cigna Commercial	$222.30
Rate for Payer: Cigna Medicare	$210.60
Rate for Payer: Medicaid All Medicaid	$215.28
Rate for Payer: Medicare All Medicare	$163.80
Rate for Payer: Monida Allegiance	$222.30
Rate for Payer: Monida First Choice Health	$226.98
Rate for Payer: Monida Montana Health Co-op	$222.30
Rate for Payer: Monida PacificSource	$222.30

Know your out-of-pocket cost for care.

All Charges