Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

SODIUM CHLORIDE 0.9% NEB SOLN [3 ML]

Facility

$8.00

Service Code	HCPCS A4216
Hospital Charge Code	3000429
Hospital Revenue Code	259
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

SODIUM CHLORIDE MOISTURIZING NASAL SPRAY

Facility

$8.00

Service Code	HCPCS J8499
Hospital Charge Code	3007353
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

SODIUM CHLORIDE MOISTURIZING NASAL SPRAY

Facility

$8.00

Service Code	HCPCS J8499
Hospital Charge Code	3007353
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

SODIUM CHLORIDE SOLN INH 7% 4 ML

Facility

$57.60

Hospital Charge Code	3007360
Hospital Revenue Code	250
Min. Negotiated Rate	$40.32
Max. Negotiated Rate	$57.60
Rate for Payer: Aetna Commercial	$54.72
Rate for Payer: Aetna Medicare	$51.84
Rate for Payer: BCBS MT CHIP	$51.84
Rate for Payer: BCBS MT Closed Plan Network	$54.72
Rate for Payer: BCBS MT HealthLink	$51.84
Rate for Payer: BCBS MT Medicare	$51.84
Rate for Payer: BCBS MT POS	$54.72
Rate for Payer: BCBS MT Traditional	$57.60
Rate for Payer: Cash Price	$51.84
Rate for Payer: Cigna Commercial	$54.72
Rate for Payer: Cigna Medicare	$51.84
Rate for Payer: Medicaid All Medicaid	$52.99
Rate for Payer: Medicare All Medicare	$40.32
Rate for Payer: Monida Allegiance	$54.72
Rate for Payer: Monida First Choice Health	$55.87
Rate for Payer: Monida Montana Health Co-op	$54.72
Rate for Payer: Monida PacificSource	$54.72

SODIUM CHLORIDE SOLN INH 7% 4 ML

Facility

$57.60

Hospital Charge Code	3007360
Hospital Revenue Code	250
Min. Negotiated Rate	$40.32
Max. Negotiated Rate	$57.60
Rate for Payer: Aetna Commercial	$54.72
Rate for Payer: Aetna Medicare	$51.84
Rate for Payer: BCBS MT CHIP	$51.84
Rate for Payer: BCBS MT Closed Plan Network	$54.72
Rate for Payer: BCBS MT HealthLink	$51.84
Rate for Payer: BCBS MT Medicare	$51.84
Rate for Payer: BCBS MT POS	$54.72
Rate for Payer: BCBS MT Traditional	$57.60
Rate for Payer: Cash Price	$51.84
Rate for Payer: Cigna Commercial	$54.72
Rate for Payer: Cigna Medicare	$51.84
Rate for Payer: Medicaid All Medicaid	$52.99
Rate for Payer: Medicare All Medicare	$40.32
Rate for Payer: Monida Allegiance	$54.72
Rate for Payer: Monida First Choice Health	$55.87
Rate for Payer: Monida Montana Health Co-op	$54.72
Rate for Payer: Monida PacificSource	$54.72

SODIUM NITRITE INJ [300 MG/10 ML]

Facility

$26.00

Service Code	HCPCS J3490
Hospital Charge Code	3000430
Hospital Revenue Code	636
Min. Negotiated Rate	$18.20
Max. Negotiated Rate	$26.00
Rate for Payer: Aetna Commercial	$24.70
Rate for Payer: Aetna Medicare	$23.40
Rate for Payer: BCBS MT CHIP	$23.40
Rate for Payer: BCBS MT Closed Plan Network	$24.70
Rate for Payer: BCBS MT HealthLink	$23.40
Rate for Payer: BCBS MT Medicare	$23.40
Rate for Payer: BCBS MT POS	$24.70
Rate for Payer: BCBS MT Traditional	$26.00
Rate for Payer: Cash Price	$23.40
Rate for Payer: Cigna Commercial	$24.70
Rate for Payer: Cigna Medicare	$23.40
Rate for Payer: Medicaid All Medicaid	$23.92
Rate for Payer: Medicare All Medicare	$18.20
Rate for Payer: Monida Allegiance	$24.70
Rate for Payer: Monida First Choice Health	$25.22
Rate for Payer: Monida Montana Health Co-op	$24.70
Rate for Payer: Monida PacificSource	$24.70

SODIUM NITRITE INJ [300 MG/10 ML]

Facility

$26.00

Service Code	HCPCS J3490
Hospital Charge Code	3000430
Hospital Revenue Code	636
Min. Negotiated Rate	$18.20
Max. Negotiated Rate	$26.00
Rate for Payer: Aetna Commercial	$24.70
Rate for Payer: Aetna Medicare	$23.40
Rate for Payer: BCBS MT CHIP	$23.40
Rate for Payer: BCBS MT Closed Plan Network	$24.70
Rate for Payer: BCBS MT HealthLink	$23.40
Rate for Payer: BCBS MT Medicare	$23.40
Rate for Payer: BCBS MT POS	$24.70
Rate for Payer: BCBS MT Traditional	$26.00
Rate for Payer: Cash Price	$23.40
Rate for Payer: Cigna Commercial	$24.70
Rate for Payer: Cigna Medicare	$23.40
Rate for Payer: Medicaid All Medicaid	$23.92
Rate for Payer: Medicare All Medicare	$18.20
Rate for Payer: Monida Allegiance	$24.70
Rate for Payer: Monida First Choice Health	$25.22
Rate for Payer: Monida Montana Health Co-op	$24.70
Rate for Payer: Monida PacificSource	$24.70

SODIUM PHOSPHATE ENEMA [1 OZ]

Facility

$8.00

Service Code	HCPCS A9150
Hospital Charge Code	3000431
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

SODIUM PHOSPHATE ENEMA [1 OZ]

Facility

$8.00

Service Code	HCPCS A9150
Hospital Charge Code	3000431
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

SODIUM POLYSTYRENE SULFONATE [15G]

Facility

$44.00

Service Code	HCPCS J8499
Hospital Charge Code	3000432
Hospital Revenue Code	250
Min. Negotiated Rate	$30.80
Max. Negotiated Rate	$44.00
Rate for Payer: Aetna Commercial	$41.80
Rate for Payer: Aetna Medicare	$39.60
Rate for Payer: BCBS MT CHIP	$39.60
Rate for Payer: BCBS MT Closed Plan Network	$41.80
Rate for Payer: BCBS MT HealthLink	$39.60
Rate for Payer: BCBS MT Medicare	$39.60
Rate for Payer: BCBS MT POS	$41.80
Rate for Payer: BCBS MT Traditional	$44.00
Rate for Payer: Cash Price	$39.60
Rate for Payer: Cigna Commercial	$41.80
Rate for Payer: Cigna Medicare	$39.60
Rate for Payer: Medicaid All Medicaid	$40.48
Rate for Payer: Medicare All Medicare	$30.80
Rate for Payer: Monida Allegiance	$41.80
Rate for Payer: Monida First Choice Health	$42.68
Rate for Payer: Monida Montana Health Co-op	$41.80
Rate for Payer: Monida PacificSource	$41.80

SODIUM POLYSTYRENE SULFONATE [15G]

Facility

$44.00

Service Code	HCPCS J8499
Hospital Charge Code	3000432
Hospital Revenue Code	250
Min. Negotiated Rate	$30.80
Max. Negotiated Rate	$44.00
Rate for Payer: Aetna Commercial	$41.80
Rate for Payer: Aetna Medicare	$39.60
Rate for Payer: BCBS MT CHIP	$39.60
Rate for Payer: BCBS MT Closed Plan Network	$41.80
Rate for Payer: BCBS MT HealthLink	$39.60
Rate for Payer: BCBS MT Medicare	$39.60
Rate for Payer: BCBS MT POS	$41.80
Rate for Payer: BCBS MT Traditional	$44.00
Rate for Payer: Cash Price	$39.60
Rate for Payer: Cigna Commercial	$41.80
Rate for Payer: Cigna Medicare	$39.60
Rate for Payer: Medicaid All Medicaid	$40.48
Rate for Payer: Medicare All Medicare	$30.80
Rate for Payer: Monida Allegiance	$41.80
Rate for Payer: Monida First Choice Health	$42.68
Rate for Payer: Monida Montana Health Co-op	$41.80
Rate for Payer: Monida PacificSource	$41.80

SODIUM, RANDOM URINE (013326)

Facility

$57.00

Service Code	CPT 84300
Hospital Charge Code	4084300
Hospital Revenue Code	300
Min. Negotiated Rate	$39.90
Max. Negotiated Rate	$57.00
Rate for Payer: Aetna Commercial	$54.15
Rate for Payer: Aetna Medicare	$51.30
Rate for Payer: BCBS MT CHIP	$51.30
Rate for Payer: BCBS MT Closed Plan Network	$54.15
Rate for Payer: BCBS MT HealthLink	$51.30
Rate for Payer: BCBS MT Medicare	$51.30
Rate for Payer: BCBS MT POS	$54.15
Rate for Payer: BCBS MT Traditional	$57.00
Rate for Payer: Cash Price	$51.30
Rate for Payer: Cigna Commercial	$54.15
Rate for Payer: Cigna Medicare	$51.30
Rate for Payer: Medicaid All Medicaid	$52.44
Rate for Payer: Medicare All Medicare	$39.90
Rate for Payer: Monida Allegiance	$54.15
Rate for Payer: Monida First Choice Health	$55.29
Rate for Payer: Monida Montana Health Co-op	$54.15
Rate for Payer: Monida PacificSource	$54.15

SODIUM, RANDOM URINE (013326)

Facility

$57.00

Service Code	CPT 84300
Hospital Charge Code	4084300
Hospital Revenue Code	300
Min. Negotiated Rate	$39.90
Max. Negotiated Rate	$57.00
Rate for Payer: Aetna Commercial	$54.15
Rate for Payer: Aetna Medicare	$51.30
Rate for Payer: BCBS MT CHIP	$51.30
Rate for Payer: BCBS MT Closed Plan Network	$54.15
Rate for Payer: BCBS MT HealthLink	$51.30
Rate for Payer: BCBS MT Medicare	$51.30
Rate for Payer: BCBS MT POS	$54.15
Rate for Payer: BCBS MT Traditional	$57.00
Rate for Payer: Cash Price	$51.30
Rate for Payer: Cigna Commercial	$54.15
Rate for Payer: Cigna Medicare	$51.30
Rate for Payer: Medicaid All Medicaid	$52.44
Rate for Payer: Medicare All Medicare	$39.90
Rate for Payer: Monida Allegiance	$54.15
Rate for Payer: Monida First Choice Health	$55.29
Rate for Payer: Monida Montana Health Co-op	$54.15
Rate for Payer: Monida PacificSource	$54.15

SOLIFENACIN SUCC TAB [10 MG] NF

Facility

$42.00

Service Code	HCPCS J8499
Hospital Charge Code	3007556
Hospital Revenue Code	250
Min. Negotiated Rate	$29.40
Max. Negotiated Rate	$42.00
Rate for Payer: Aetna Commercial	$39.90
Rate for Payer: Aetna Medicare	$37.80
Rate for Payer: BCBS MT CHIP	$37.80
Rate for Payer: BCBS MT Closed Plan Network	$39.90
Rate for Payer: BCBS MT HealthLink	$37.80
Rate for Payer: BCBS MT Medicare	$37.80
Rate for Payer: BCBS MT POS	$39.90
Rate for Payer: BCBS MT Traditional	$42.00
Rate for Payer: Cash Price	$37.80
Rate for Payer: Cigna Commercial	$39.90
Rate for Payer: Cigna Medicare	$37.80
Rate for Payer: Medicaid All Medicaid	$38.64
Rate for Payer: Medicare All Medicare	$29.40
Rate for Payer: Monida Allegiance	$39.90
Rate for Payer: Monida First Choice Health	$40.74
Rate for Payer: Monida Montana Health Co-op	$39.90
Rate for Payer: Monida PacificSource	$39.90

SOLIFENACIN SUCC TAB [10 MG] NF

Facility

$42.00

Service Code	HCPCS J8499
Hospital Charge Code	3007556
Hospital Revenue Code	250
Min. Negotiated Rate	$29.40
Max. Negotiated Rate	$42.00
Rate for Payer: Aetna Commercial	$39.90
Rate for Payer: Aetna Medicare	$37.80
Rate for Payer: BCBS MT CHIP	$37.80
Rate for Payer: BCBS MT Closed Plan Network	$39.90
Rate for Payer: BCBS MT HealthLink	$37.80
Rate for Payer: BCBS MT Medicare	$37.80
Rate for Payer: BCBS MT POS	$39.90
Rate for Payer: BCBS MT Traditional	$42.00
Rate for Payer: Cash Price	$37.80
Rate for Payer: Cigna Commercial	$39.90
Rate for Payer: Cigna Medicare	$37.80
Rate for Payer: Medicaid All Medicaid	$38.64
Rate for Payer: Medicare All Medicare	$29.40
Rate for Payer: Monida Allegiance	$39.90
Rate for Payer: Monida First Choice Health	$40.74
Rate for Payer: Monida Montana Health Co-op	$39.90
Rate for Payer: Monida PacificSource	$39.90

SOLIFENACIN TAB [5 MG] NF

Facility

$42.00

Service Code	HCPCS J8499
Hospital Charge Code	3007287
Hospital Revenue Code	250
Min. Negotiated Rate	$29.40
Max. Negotiated Rate	$42.00
Rate for Payer: Aetna Commercial	$39.90
Rate for Payer: Aetna Medicare	$37.80
Rate for Payer: BCBS MT CHIP	$37.80
Rate for Payer: BCBS MT Closed Plan Network	$39.90
Rate for Payer: BCBS MT HealthLink	$37.80
Rate for Payer: BCBS MT Medicare	$37.80
Rate for Payer: BCBS MT POS	$39.90
Rate for Payer: BCBS MT Traditional	$42.00
Rate for Payer: Cash Price	$37.80
Rate for Payer: Cigna Commercial	$39.90
Rate for Payer: Cigna Medicare	$37.80
Rate for Payer: Medicaid All Medicaid	$38.64
Rate for Payer: Medicare All Medicare	$29.40
Rate for Payer: Monida Allegiance	$39.90
Rate for Payer: Monida First Choice Health	$40.74
Rate for Payer: Monida Montana Health Co-op	$39.90
Rate for Payer: Monida PacificSource	$39.90

SOLIFENACIN TAB [5 MG] NF

Facility

$42.00

Service Code	HCPCS J8499
Hospital Charge Code	3007287
Hospital Revenue Code	250
Min. Negotiated Rate	$29.40
Max. Negotiated Rate	$42.00
Rate for Payer: Aetna Commercial	$39.90
Rate for Payer: Aetna Medicare	$37.80
Rate for Payer: BCBS MT CHIP	$37.80
Rate for Payer: BCBS MT Closed Plan Network	$39.90
Rate for Payer: BCBS MT HealthLink	$37.80
Rate for Payer: BCBS MT Medicare	$37.80
Rate for Payer: BCBS MT POS	$39.90
Rate for Payer: BCBS MT Traditional	$42.00
Rate for Payer: Cash Price	$37.80
Rate for Payer: Cigna Commercial	$39.90
Rate for Payer: Cigna Medicare	$37.80
Rate for Payer: Medicaid All Medicaid	$38.64
Rate for Payer: Medicare All Medicare	$29.40
Rate for Payer: Monida Allegiance	$39.90
Rate for Payer: Monida First Choice Health	$40.74
Rate for Payer: Monida Montana Health Co-op	$39.90
Rate for Payer: Monida PacificSource	$39.90

SOMATOSTATIN QUANTI

Facility

$264.00

Service Code	CPT 84307
Hospital Charge Code	4088055
Hospital Revenue Code	302
Min. Negotiated Rate	$184.80
Max. Negotiated Rate	$264.00
Rate for Payer: Aetna Commercial	$250.80
Rate for Payer: Aetna Medicare	$237.60
Rate for Payer: BCBS MT CHIP	$237.60
Rate for Payer: BCBS MT Closed Plan Network	$250.80
Rate for Payer: BCBS MT HealthLink	$237.60
Rate for Payer: BCBS MT Medicare	$237.60
Rate for Payer: BCBS MT POS	$250.80
Rate for Payer: BCBS MT Traditional	$264.00
Rate for Payer: Cash Price	$237.60
Rate for Payer: Cigna Commercial	$250.80
Rate for Payer: Cigna Medicare	$237.60
Rate for Payer: Medicaid All Medicaid	$242.88
Rate for Payer: Medicare All Medicare	$184.80
Rate for Payer: Monida Allegiance	$250.80
Rate for Payer: Monida First Choice Health	$256.08
Rate for Payer: Monida Montana Health Co-op	$250.80
Rate for Payer: Monida PacificSource	$250.80

SOMATOSTATIN QUANTI

Facility

$264.00

Service Code	CPT 84307
Hospital Charge Code	4088055
Hospital Revenue Code	302
Min. Negotiated Rate	$184.80
Max. Negotiated Rate	$264.00
Rate for Payer: Aetna Commercial	$250.80
Rate for Payer: Aetna Medicare	$237.60
Rate for Payer: BCBS MT CHIP	$237.60
Rate for Payer: BCBS MT Closed Plan Network	$250.80
Rate for Payer: BCBS MT HealthLink	$237.60
Rate for Payer: BCBS MT Medicare	$237.60
Rate for Payer: BCBS MT POS	$250.80
Rate for Payer: BCBS MT Traditional	$264.00
Rate for Payer: Cash Price	$237.60
Rate for Payer: Cigna Commercial	$250.80
Rate for Payer: Cigna Medicare	$237.60
Rate for Payer: Medicaid All Medicaid	$242.88
Rate for Payer: Medicare All Medicare	$184.80
Rate for Payer: Monida Allegiance	$250.80
Rate for Payer: Monida First Choice Health	$256.08
Rate for Payer: Monida Montana Health Co-op	$250.80
Rate for Payer: Monida PacificSource	$250.80

SOTALOL TAB [80 MG] NF

Facility

$9.00

Service Code	HCPCS J8499
Hospital Charge Code	3000433
Hospital Revenue Code	250
Min. Negotiated Rate	$6.30
Max. Negotiated Rate	$9.00
Rate for Payer: Aetna Commercial	$8.55
Rate for Payer: Aetna Medicare	$8.10
Rate for Payer: BCBS MT CHIP	$8.10
Rate for Payer: BCBS MT Closed Plan Network	$8.55
Rate for Payer: BCBS MT HealthLink	$8.10
Rate for Payer: BCBS MT Medicare	$8.10
Rate for Payer: BCBS MT POS	$8.55
Rate for Payer: BCBS MT Traditional	$9.00
Rate for Payer: Cash Price	$8.10
Rate for Payer: Cigna Commercial	$8.55
Rate for Payer: Cigna Medicare	$8.10
Rate for Payer: Medicaid All Medicaid	$8.28
Rate for Payer: Medicare All Medicare	$6.30
Rate for Payer: Monida Allegiance	$8.55
Rate for Payer: Monida First Choice Health	$8.73
Rate for Payer: Monida Montana Health Co-op	$8.55
Rate for Payer: Monida PacificSource	$8.55

SOTALOL TAB [80 MG] NF

Facility

$9.00

Service Code	HCPCS J8499
Hospital Charge Code	3000433
Hospital Revenue Code	250
Min. Negotiated Rate	$6.30
Max. Negotiated Rate	$9.00
Rate for Payer: Aetna Commercial	$8.55
Rate for Payer: Aetna Medicare	$8.10
Rate for Payer: BCBS MT CHIP	$8.10
Rate for Payer: BCBS MT Closed Plan Network	$8.55
Rate for Payer: BCBS MT HealthLink	$8.10
Rate for Payer: BCBS MT Medicare	$8.10
Rate for Payer: BCBS MT POS	$8.55
Rate for Payer: BCBS MT Traditional	$9.00
Rate for Payer: Cash Price	$8.10
Rate for Payer: Cigna Commercial	$8.55
Rate for Payer: Cigna Medicare	$8.10
Rate for Payer: Medicaid All Medicaid	$8.28
Rate for Payer: Medicare All Medicare	$6.30
Rate for Payer: Monida Allegiance	$8.55
Rate for Payer: Monida First Choice Health	$8.73
Rate for Payer: Monida Montana Health Co-op	$8.55
Rate for Payer: Monida PacificSource	$8.55

SPECIAL STAIN GROUP 1 MICROORGANISMS I&R

Facility

$299.00

Service Code	CPT 88312
Hospital Charge Code	8088312
Hospital Revenue Code	521
Min. Negotiated Rate	$209.30
Max. Negotiated Rate	$299.00
Rate for Payer: Aetna Commercial	$284.05
Rate for Payer: Aetna Medicare	$269.10
Rate for Payer: BCBS MT CHIP	$269.10
Rate for Payer: BCBS MT Closed Plan Network	$284.05
Rate for Payer: BCBS MT HealthLink	$269.10
Rate for Payer: BCBS MT Medicare	$269.10
Rate for Payer: BCBS MT POS	$284.05
Rate for Payer: BCBS MT Traditional	$299.00
Rate for Payer: Cash Price	$269.10
Rate for Payer: Cigna Commercial	$284.05
Rate for Payer: Cigna Medicare	$269.10
Rate for Payer: Medicaid All Medicaid	$275.08
Rate for Payer: Medicare All Medicare	$209.30
Rate for Payer: Monida Allegiance	$284.05
Rate for Payer: Monida First Choice Health	$290.03
Rate for Payer: Monida Montana Health Co-op	$284.05
Rate for Payer: Monida PacificSource	$284.05

SPECIAL STAIN GROUP 1 MICROORGANISMS I&R

Facility

$299.00

Service Code	CPT 88312
Hospital Charge Code	8088312
Hospital Revenue Code	521
Min. Negotiated Rate	$209.30
Max. Negotiated Rate	$299.00
Rate for Payer: Aetna Commercial	$284.05
Rate for Payer: Aetna Medicare	$269.10
Rate for Payer: BCBS MT CHIP	$269.10
Rate for Payer: BCBS MT Closed Plan Network	$284.05
Rate for Payer: BCBS MT HealthLink	$269.10
Rate for Payer: BCBS MT Medicare	$269.10
Rate for Payer: BCBS MT POS	$284.05
Rate for Payer: BCBS MT Traditional	$299.00
Rate for Payer: Cash Price	$269.10
Rate for Payer: Cigna Commercial	$284.05
Rate for Payer: Cigna Medicare	$269.10
Rate for Payer: Medicaid All Medicaid	$275.08
Rate for Payer: Medicare All Medicare	$209.30
Rate for Payer: Monida Allegiance	$284.05
Rate for Payer: Monida First Choice Health	$290.03
Rate for Payer: Monida Montana Health Co-op	$284.05
Rate for Payer: Monida PacificSource	$284.05

SPECIMEN HANDLING CHARGE

Facility

$27.00

Service Code	CPT 99001
Hospital Charge Code	4099000
Hospital Revenue Code	300
Min. Negotiated Rate	$18.90
Max. Negotiated Rate	$27.00
Rate for Payer: Aetna Commercial	$25.65
Rate for Payer: Aetna Medicare	$24.30
Rate for Payer: BCBS MT CHIP	$24.30
Rate for Payer: BCBS MT Closed Plan Network	$25.65
Rate for Payer: BCBS MT HealthLink	$24.30
Rate for Payer: BCBS MT Medicare	$24.30
Rate for Payer: BCBS MT POS	$25.65
Rate for Payer: BCBS MT Traditional	$27.00
Rate for Payer: Cash Price	$24.30
Rate for Payer: Cigna Commercial	$25.65
Rate for Payer: Cigna Medicare	$24.30
Rate for Payer: Medicaid All Medicaid	$24.84
Rate for Payer: Medicare All Medicare	$18.90
Rate for Payer: Monida Allegiance	$25.65
Rate for Payer: Monida First Choice Health	$26.19
Rate for Payer: Monida Montana Health Co-op	$25.65
Rate for Payer: Monida PacificSource	$25.65

SPECIMEN HANDLING CHARGE

Facility

$27.00

Service Code	CPT 99001
Hospital Charge Code	4099000
Hospital Revenue Code	300
Min. Negotiated Rate	$18.90
Max. Negotiated Rate	$27.00
Rate for Payer: Aetna Commercial	$25.65
Rate for Payer: Aetna Medicare	$24.30
Rate for Payer: BCBS MT CHIP	$24.30
Rate for Payer: BCBS MT Closed Plan Network	$25.65
Rate for Payer: BCBS MT HealthLink	$24.30
Rate for Payer: BCBS MT Medicare	$24.30
Rate for Payer: BCBS MT POS	$25.65
Rate for Payer: BCBS MT Traditional	$27.00
Rate for Payer: Cash Price	$24.30
Rate for Payer: Cigna Commercial	$25.65
Rate for Payer: Cigna Medicare	$24.30
Rate for Payer: Medicaid All Medicaid	$24.84
Rate for Payer: Medicare All Medicare	$18.90
Rate for Payer: Monida Allegiance	$25.65
Rate for Payer: Monida First Choice Health	$26.19
Rate for Payer: Monida Montana Health Co-op	$25.65
Rate for Payer: Monida PacificSource	$25.65

Know your out-of-pocket cost for care.

All Charges