Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

SPLINT COLLES RT/MED. PADDED

Facility

$22.00

Hospital Charge Code	2893523
Hospital Revenue Code	290
Min. Negotiated Rate	$15.40
Max. Negotiated Rate	$22.00
Rate for Payer: Aetna Commercial	$20.90
Rate for Payer: Aetna Medicare	$19.80
Rate for Payer: BCBS MT CHIP	$19.80
Rate for Payer: BCBS MT Closed Plan Network	$20.90
Rate for Payer: BCBS MT HealthLink	$19.80
Rate for Payer: BCBS MT Medicare	$19.80
Rate for Payer: BCBS MT POS	$20.90
Rate for Payer: BCBS MT Traditional	$22.00
Rate for Payer: Cash Price	$19.80
Rate for Payer: Cigna Commercial	$20.90
Rate for Payer: Cigna Medicare	$19.80
Rate for Payer: Medicaid All Medicaid	$20.24
Rate for Payer: Medicare All Medicare	$15.40
Rate for Payer: Monida Allegiance	$20.90
Rate for Payer: Monida First Choice Health	$21.34
Rate for Payer: Monida Montana Health Co-op	$20.90
Rate for Payer: Monida PacificSource	$20.90

SPLINT COLLES RT/SM PADDED

Facility

$22.00

Hospital Charge Code	2893522
Hospital Revenue Code	290
Min. Negotiated Rate	$15.40
Max. Negotiated Rate	$22.00
Rate for Payer: Aetna Commercial	$20.90
Rate for Payer: Aetna Medicare	$19.80
Rate for Payer: BCBS MT CHIP	$19.80
Rate for Payer: BCBS MT Closed Plan Network	$20.90
Rate for Payer: BCBS MT HealthLink	$19.80
Rate for Payer: BCBS MT Medicare	$19.80
Rate for Payer: BCBS MT POS	$20.90
Rate for Payer: BCBS MT Traditional	$22.00
Rate for Payer: Cash Price	$19.80
Rate for Payer: Cigna Commercial	$20.90
Rate for Payer: Cigna Medicare	$19.80
Rate for Payer: Medicaid All Medicaid	$20.24
Rate for Payer: Medicare All Medicare	$15.40
Rate for Payer: Monida Allegiance	$20.90
Rate for Payer: Monida First Choice Health	$21.34
Rate for Payer: Monida Montana Health Co-op	$20.90
Rate for Payer: Monida PacificSource	$20.90

SPLINT COLLES RT/SM PADDED

Facility

$22.00

Hospital Charge Code	2893522
Hospital Revenue Code	290
Min. Negotiated Rate	$15.40
Max. Negotiated Rate	$22.00
Rate for Payer: Aetna Commercial	$20.90
Rate for Payer: Aetna Medicare	$19.80
Rate for Payer: BCBS MT CHIP	$19.80
Rate for Payer: BCBS MT Closed Plan Network	$20.90
Rate for Payer: BCBS MT HealthLink	$19.80
Rate for Payer: BCBS MT Medicare	$19.80
Rate for Payer: BCBS MT POS	$20.90
Rate for Payer: BCBS MT Traditional	$22.00
Rate for Payer: Cash Price	$19.80
Rate for Payer: Cigna Commercial	$20.90
Rate for Payer: Cigna Medicare	$19.80
Rate for Payer: Medicaid All Medicaid	$20.24
Rate for Payer: Medicare All Medicare	$15.40
Rate for Payer: Monida Allegiance	$20.90
Rate for Payer: Monida First Choice Health	$21.34
Rate for Payer: Monida Montana Health Co-op	$20.90
Rate for Payer: Monida PacificSource	$20.90

SPLINT COLLES RT/XSM PADDED

Facility

$22.00

Hospital Charge Code	2893521
Hospital Revenue Code	290
Min. Negotiated Rate	$15.40
Max. Negotiated Rate	$22.00
Rate for Payer: Aetna Commercial	$20.90
Rate for Payer: Aetna Medicare	$19.80
Rate for Payer: BCBS MT CHIP	$19.80
Rate for Payer: BCBS MT Closed Plan Network	$20.90
Rate for Payer: BCBS MT HealthLink	$19.80
Rate for Payer: BCBS MT Medicare	$19.80
Rate for Payer: BCBS MT POS	$20.90
Rate for Payer: BCBS MT Traditional	$22.00
Rate for Payer: Cash Price	$19.80
Rate for Payer: Cigna Commercial	$20.90
Rate for Payer: Cigna Medicare	$19.80
Rate for Payer: Medicaid All Medicaid	$20.24
Rate for Payer: Medicare All Medicare	$15.40
Rate for Payer: Monida Allegiance	$20.90
Rate for Payer: Monida First Choice Health	$21.34
Rate for Payer: Monida Montana Health Co-op	$20.90
Rate for Payer: Monida PacificSource	$20.90

SPLINT COLLES RT/XSM PADDED

Facility

$22.00

Hospital Charge Code	2893521
Hospital Revenue Code	290
Min. Negotiated Rate	$15.40
Max. Negotiated Rate	$22.00
Rate for Payer: Aetna Commercial	$20.90
Rate for Payer: Aetna Medicare	$19.80
Rate for Payer: BCBS MT CHIP	$19.80
Rate for Payer: BCBS MT Closed Plan Network	$20.90
Rate for Payer: BCBS MT HealthLink	$19.80
Rate for Payer: BCBS MT Medicare	$19.80
Rate for Payer: BCBS MT POS	$20.90
Rate for Payer: BCBS MT Traditional	$22.00
Rate for Payer: Cash Price	$19.80
Rate for Payer: Cigna Commercial	$20.90
Rate for Payer: Cigna Medicare	$19.80
Rate for Payer: Medicaid All Medicaid	$20.24
Rate for Payer: Medicare All Medicare	$15.40
Rate for Payer: Monida Allegiance	$20.90
Rate for Payer: Monida First Choice Health	$21.34
Rate for Payer: Monida Montana Health Co-op	$20.90
Rate for Payer: Monida PacificSource	$20.90

SPLINT LARGE

Facility

$495.00

Hospital Charge Code	1050859
Hospital Revenue Code	230
Min. Negotiated Rate	$346.50
Max. Negotiated Rate	$495.00
Rate for Payer: Aetna Commercial	$470.25
Rate for Payer: Aetna Medicare	$445.50
Rate for Payer: BCBS MT CHIP	$445.50
Rate for Payer: BCBS MT Closed Plan Network	$470.25
Rate for Payer: BCBS MT HealthLink	$445.50
Rate for Payer: BCBS MT Medicare	$445.50
Rate for Payer: BCBS MT POS	$470.25
Rate for Payer: BCBS MT Traditional	$495.00
Rate for Payer: Cash Price	$445.50
Rate for Payer: Cigna Commercial	$470.25
Rate for Payer: Cigna Medicare	$445.50
Rate for Payer: Medicaid All Medicaid	$455.40
Rate for Payer: Medicare All Medicare	$346.50
Rate for Payer: Monida Allegiance	$470.25
Rate for Payer: Monida First Choice Health	$480.15
Rate for Payer: Monida Montana Health Co-op	$470.25
Rate for Payer: Monida PacificSource	$470.25

SPLINT LARGE

Facility

$495.00

Hospital Charge Code	1050859
Hospital Revenue Code	230
Min. Negotiated Rate	$346.50
Max. Negotiated Rate	$495.00
Rate for Payer: Aetna Commercial	$470.25
Rate for Payer: Aetna Medicare	$445.50
Rate for Payer: BCBS MT CHIP	$445.50
Rate for Payer: BCBS MT Closed Plan Network	$470.25
Rate for Payer: BCBS MT HealthLink	$445.50
Rate for Payer: BCBS MT Medicare	$445.50
Rate for Payer: BCBS MT POS	$470.25
Rate for Payer: BCBS MT Traditional	$495.00
Rate for Payer: Cash Price	$445.50
Rate for Payer: Cigna Commercial	$470.25
Rate for Payer: Cigna Medicare	$445.50
Rate for Payer: Medicaid All Medicaid	$455.40
Rate for Payer: Medicare All Medicare	$346.50
Rate for Payer: Monida Allegiance	$470.25
Rate for Payer: Monida First Choice Health	$480.15
Rate for Payer: Monida Montana Health Co-op	$470.25
Rate for Payer: Monida PacificSource	$470.25

SPLINT WRIST/HAND

Facility

$121.00

Service Code	HCPCS L3908
Hospital Charge Code	8003908
Hospital Revenue Code	290
Min. Negotiated Rate	$84.70
Max. Negotiated Rate	$121.00
Rate for Payer: Aetna Commercial	$114.95
Rate for Payer: Aetna Medicare	$108.90
Rate for Payer: BCBS MT CHIP	$108.90
Rate for Payer: BCBS MT Closed Plan Network	$114.95
Rate for Payer: BCBS MT HealthLink	$108.90
Rate for Payer: BCBS MT Medicare	$108.90
Rate for Payer: BCBS MT POS	$114.95
Rate for Payer: BCBS MT Traditional	$121.00
Rate for Payer: Cash Price	$108.90
Rate for Payer: Cigna Commercial	$114.95
Rate for Payer: Cigna Medicare	$108.90
Rate for Payer: Medicaid All Medicaid	$111.32
Rate for Payer: Medicare All Medicare	$84.70
Rate for Payer: Monida Allegiance	$114.95
Rate for Payer: Monida First Choice Health	$117.37
Rate for Payer: Monida Montana Health Co-op	$114.95
Rate for Payer: Monida PacificSource	$114.95

SPLINT WRIST/HAND

Facility

$121.00

Service Code	HCPCS L3908
Hospital Charge Code	8003908
Hospital Revenue Code	290
Min. Negotiated Rate	$84.70
Max. Negotiated Rate	$121.00
Rate for Payer: Aetna Commercial	$114.95
Rate for Payer: Aetna Medicare	$108.90
Rate for Payer: BCBS MT CHIP	$108.90
Rate for Payer: BCBS MT Closed Plan Network	$114.95
Rate for Payer: BCBS MT HealthLink	$108.90
Rate for Payer: BCBS MT Medicare	$108.90
Rate for Payer: BCBS MT POS	$114.95
Rate for Payer: BCBS MT Traditional	$121.00
Rate for Payer: Cash Price	$108.90
Rate for Payer: Cigna Commercial	$114.95
Rate for Payer: Cigna Medicare	$108.90
Rate for Payer: Medicaid All Medicaid	$111.32
Rate for Payer: Medicare All Medicare	$84.70
Rate for Payer: Monida Allegiance	$114.95
Rate for Payer: Monida First Choice Health	$117.37
Rate for Payer: Monida Montana Health Co-op	$114.95
Rate for Payer: Monida PacificSource	$114.95

SPOTFIRE RESPI PANEL

Facility

$2,250.00

Hospital Charge Code	90197176
Hospital Revenue Code	270
Min. Negotiated Rate	$1,575.00
Max. Negotiated Rate	$2,250.00
Rate for Payer: Aetna Commercial	$2,137.50
Rate for Payer: Aetna Medicare	$2,025.00
Rate for Payer: BCBS MT CHIP	$2,025.00
Rate for Payer: BCBS MT Closed Plan Network	$2,137.50
Rate for Payer: BCBS MT HealthLink	$2,025.00
Rate for Payer: BCBS MT Medicare	$2,025.00
Rate for Payer: BCBS MT POS	$2,137.50
Rate for Payer: BCBS MT Traditional	$2,250.00
Rate for Payer: Cash Price	$2,025.00
Rate for Payer: Cigna Commercial	$2,137.50
Rate for Payer: Cigna Medicare	$2,025.00
Rate for Payer: Medicaid All Medicaid	$2,070.00
Rate for Payer: Medicare All Medicare	$1,575.00
Rate for Payer: Monida Allegiance	$2,137.50
Rate for Payer: Monida First Choice Health	$2,182.50
Rate for Payer: Monida Montana Health Co-op	$2,137.50
Rate for Payer: Monida PacificSource	$2,137.50

SPOTFIRE RESPI PANEL

Facility

$2,250.00

Hospital Charge Code	90197176
Hospital Revenue Code	270
Min. Negotiated Rate	$1,575.00
Max. Negotiated Rate	$2,250.00
Rate for Payer: Aetna Commercial	$2,137.50
Rate for Payer: Aetna Medicare	$2,025.00
Rate for Payer: BCBS MT CHIP	$2,025.00
Rate for Payer: BCBS MT Closed Plan Network	$2,137.50
Rate for Payer: BCBS MT HealthLink	$2,025.00
Rate for Payer: BCBS MT Medicare	$2,025.00
Rate for Payer: BCBS MT POS	$2,137.50
Rate for Payer: BCBS MT Traditional	$2,250.00
Rate for Payer: Cash Price	$2,025.00
Rate for Payer: Cigna Commercial	$2,137.50
Rate for Payer: Cigna Medicare	$2,025.00
Rate for Payer: Medicaid All Medicaid	$2,070.00
Rate for Payer: Medicare All Medicare	$1,575.00
Rate for Payer: Monida Allegiance	$2,137.50
Rate for Payer: Monida First Choice Health	$2,182.50
Rate for Payer: Monida Montana Health Co-op	$2,137.50
Rate for Payer: Monida PacificSource	$2,137.50

SPOTFIRE RESPI PANEL QC M425

Facility

$380.00

Hospital Charge Code	90197177
Hospital Revenue Code	270
Min. Negotiated Rate	$266.00
Max. Negotiated Rate	$380.00
Rate for Payer: Aetna Commercial	$361.00
Rate for Payer: Aetna Medicare	$342.00
Rate for Payer: BCBS MT CHIP	$342.00
Rate for Payer: BCBS MT Closed Plan Network	$361.00
Rate for Payer: BCBS MT HealthLink	$342.00
Rate for Payer: BCBS MT Medicare	$342.00
Rate for Payer: BCBS MT POS	$361.00
Rate for Payer: BCBS MT Traditional	$380.00
Rate for Payer: Cash Price	$342.00
Rate for Payer: Cigna Commercial	$361.00
Rate for Payer: Cigna Medicare	$342.00
Rate for Payer: Medicaid All Medicaid	$349.60
Rate for Payer: Medicare All Medicare	$266.00
Rate for Payer: Monida Allegiance	$361.00
Rate for Payer: Monida First Choice Health	$368.60
Rate for Payer: Monida Montana Health Co-op	$361.00
Rate for Payer: Monida PacificSource	$361.00

SPOTFIRE RESPI PANEL QC M425

Facility

$380.00

Hospital Charge Code	90197177
Hospital Revenue Code	270
Min. Negotiated Rate	$266.00
Max. Negotiated Rate	$380.00
Rate for Payer: Aetna Commercial	$361.00
Rate for Payer: Aetna Medicare	$342.00
Rate for Payer: BCBS MT CHIP	$342.00
Rate for Payer: BCBS MT Closed Plan Network	$361.00
Rate for Payer: BCBS MT HealthLink	$342.00
Rate for Payer: BCBS MT Medicare	$342.00
Rate for Payer: BCBS MT POS	$361.00
Rate for Payer: BCBS MT Traditional	$380.00
Rate for Payer: Cash Price	$342.00
Rate for Payer: Cigna Commercial	$361.00
Rate for Payer: Cigna Medicare	$342.00
Rate for Payer: Medicaid All Medicaid	$349.60
Rate for Payer: Medicare All Medicare	$266.00
Rate for Payer: Monida Allegiance	$361.00
Rate for Payer: Monida First Choice Health	$368.60
Rate for Payer: Monida Montana Health Co-op	$361.00
Rate for Payer: Monida PacificSource	$361.00

.SPUTUM CULTURE REFLEX

Facility

$64.00

Service Code	CPT 87070
Hospital Charge Code	4070704
Hospital Revenue Code	306
Min. Negotiated Rate	$44.80
Max. Negotiated Rate	$64.00
Rate for Payer: Aetna Commercial	$60.80
Rate for Payer: Aetna Medicare	$57.60
Rate for Payer: BCBS MT CHIP	$57.60
Rate for Payer: BCBS MT Closed Plan Network	$60.80
Rate for Payer: BCBS MT HealthLink	$57.60
Rate for Payer: BCBS MT Medicare	$57.60
Rate for Payer: BCBS MT POS	$60.80
Rate for Payer: BCBS MT Traditional	$64.00
Rate for Payer: Cash Price	$57.60
Rate for Payer: Cigna Commercial	$60.80
Rate for Payer: Cigna Medicare	$57.60
Rate for Payer: Medicaid All Medicaid	$58.88
Rate for Payer: Medicare All Medicare	$44.80
Rate for Payer: Monida Allegiance	$60.80
Rate for Payer: Monida First Choice Health	$62.08
Rate for Payer: Monida Montana Health Co-op	$60.80
Rate for Payer: Monida PacificSource	$60.80

.SPUTUM CULTURE REFLEX

Facility

$64.00

Service Code	CPT 87070
Hospital Charge Code	4070704
Hospital Revenue Code	306
Min. Negotiated Rate	$44.80
Max. Negotiated Rate	$64.00
Rate for Payer: Aetna Commercial	$60.80
Rate for Payer: Aetna Medicare	$57.60
Rate for Payer: BCBS MT CHIP	$57.60
Rate for Payer: BCBS MT Closed Plan Network	$60.80
Rate for Payer: BCBS MT HealthLink	$57.60
Rate for Payer: BCBS MT Medicare	$57.60
Rate for Payer: BCBS MT POS	$60.80
Rate for Payer: BCBS MT Traditional	$64.00
Rate for Payer: Cash Price	$57.60
Rate for Payer: Cigna Commercial	$60.80
Rate for Payer: Cigna Medicare	$57.60
Rate for Payer: Medicaid All Medicaid	$58.88
Rate for Payer: Medicare All Medicare	$44.80
Rate for Payer: Monida Allegiance	$60.80
Rate for Payer: Monida First Choice Health	$62.08
Rate for Payer: Monida Montana Health Co-op	$60.80
Rate for Payer: Monida PacificSource	$60.80

SPUTUM CULTURE W AFB SMEAR

Facility

$180.00

Service Code	CPT 87070
Hospital Charge Code	4088041
Hospital Revenue Code	302
Min. Negotiated Rate	$126.00
Max. Negotiated Rate	$180.00
Rate for Payer: Aetna Commercial	$171.00
Rate for Payer: Aetna Medicare	$162.00
Rate for Payer: BCBS MT CHIP	$162.00
Rate for Payer: BCBS MT Closed Plan Network	$171.00
Rate for Payer: BCBS MT HealthLink	$162.00
Rate for Payer: BCBS MT Medicare	$162.00
Rate for Payer: BCBS MT POS	$171.00
Rate for Payer: BCBS MT Traditional	$180.00
Rate for Payer: Cash Price	$162.00
Rate for Payer: Cigna Commercial	$171.00
Rate for Payer: Cigna Medicare	$162.00
Rate for Payer: Medicaid All Medicaid	$165.60
Rate for Payer: Medicare All Medicare	$126.00
Rate for Payer: Monida Allegiance	$171.00
Rate for Payer: Monida First Choice Health	$174.60
Rate for Payer: Monida Montana Health Co-op	$171.00
Rate for Payer: Monida PacificSource	$171.00

SPUTUM CULTURE W AFB SMEAR

Facility

$180.00

Service Code	CPT 87070
Hospital Charge Code	4088041
Hospital Revenue Code	302
Min. Negotiated Rate	$126.00
Max. Negotiated Rate	$180.00
Rate for Payer: Aetna Commercial	$171.00
Rate for Payer: Aetna Medicare	$162.00
Rate for Payer: BCBS MT CHIP	$162.00
Rate for Payer: BCBS MT Closed Plan Network	$171.00
Rate for Payer: BCBS MT HealthLink	$162.00
Rate for Payer: BCBS MT Medicare	$162.00
Rate for Payer: BCBS MT POS	$171.00
Rate for Payer: BCBS MT Traditional	$180.00
Rate for Payer: Cash Price	$162.00
Rate for Payer: Cigna Commercial	$171.00
Rate for Payer: Cigna Medicare	$162.00
Rate for Payer: Medicaid All Medicaid	$165.60
Rate for Payer: Medicare All Medicare	$126.00
Rate for Payer: Monida Allegiance	$171.00
Rate for Payer: Monida First Choice Health	$174.60
Rate for Payer: Monida Montana Health Co-op	$171.00
Rate for Payer: Monida PacificSource	$171.00

SS-A/RO ANTIBODIES, IGG (012682)

Facility

$114.00

Service Code	CPT 86235
Hospital Charge Code	4000066
Hospital Revenue Code	300
Min. Negotiated Rate	$79.80
Max. Negotiated Rate	$114.00
Rate for Payer: Aetna Commercial	$108.30
Rate for Payer: Aetna Medicare	$102.60
Rate for Payer: BCBS MT CHIP	$102.60
Rate for Payer: BCBS MT Closed Plan Network	$108.30
Rate for Payer: BCBS MT HealthLink	$102.60
Rate for Payer: BCBS MT Medicare	$102.60
Rate for Payer: BCBS MT POS	$108.30
Rate for Payer: BCBS MT Traditional	$114.00
Rate for Payer: Cash Price	$102.60
Rate for Payer: Cigna Commercial	$108.30
Rate for Payer: Cigna Medicare	$102.60
Rate for Payer: Medicaid All Medicaid	$104.88
Rate for Payer: Medicare All Medicare	$79.80
Rate for Payer: Monida Allegiance	$108.30
Rate for Payer: Monida First Choice Health	$110.58
Rate for Payer: Monida Montana Health Co-op	$108.30
Rate for Payer: Monida PacificSource	$108.30

SS-A/RO ANTIBODIES, IGG (012682)

Facility

$114.00

Service Code	CPT 86235
Hospital Charge Code	4000066
Hospital Revenue Code	300
Min. Negotiated Rate	$79.80
Max. Negotiated Rate	$114.00
Rate for Payer: Aetna Commercial	$108.30
Rate for Payer: Aetna Medicare	$102.60
Rate for Payer: BCBS MT CHIP	$102.60
Rate for Payer: BCBS MT Closed Plan Network	$108.30
Rate for Payer: BCBS MT HealthLink	$102.60
Rate for Payer: BCBS MT Medicare	$102.60
Rate for Payer: BCBS MT POS	$108.30
Rate for Payer: BCBS MT Traditional	$114.00
Rate for Payer: Cash Price	$102.60
Rate for Payer: Cigna Commercial	$108.30
Rate for Payer: Cigna Medicare	$102.60
Rate for Payer: Medicaid All Medicaid	$104.88
Rate for Payer: Medicare All Medicare	$79.80
Rate for Payer: Monida Allegiance	$108.30
Rate for Payer: Monida First Choice Health	$110.58
Rate for Payer: Monida Montana Health Co-op	$108.30
Rate for Payer: Monida PacificSource	$108.30

SS-B/LA ANTIBODIES, IGG (012690)

Facility

$114.00

Service Code	CPT 86235
Hospital Charge Code	4000067
Hospital Revenue Code	300
Min. Negotiated Rate	$79.80
Max. Negotiated Rate	$114.00
Rate for Payer: Aetna Commercial	$108.30
Rate for Payer: Aetna Medicare	$102.60
Rate for Payer: BCBS MT CHIP	$102.60
Rate for Payer: BCBS MT Closed Plan Network	$108.30
Rate for Payer: BCBS MT HealthLink	$102.60
Rate for Payer: BCBS MT Medicare	$102.60
Rate for Payer: BCBS MT POS	$108.30
Rate for Payer: BCBS MT Traditional	$114.00
Rate for Payer: Cash Price	$102.60
Rate for Payer: Cigna Commercial	$108.30
Rate for Payer: Cigna Medicare	$102.60
Rate for Payer: Medicaid All Medicaid	$104.88
Rate for Payer: Medicare All Medicare	$79.80
Rate for Payer: Monida Allegiance	$108.30
Rate for Payer: Monida First Choice Health	$110.58
Rate for Payer: Monida Montana Health Co-op	$108.30
Rate for Payer: Monida PacificSource	$108.30

SS-B/LA ANTIBODIES, IGG (012690)

Facility

$114.00

Service Code	CPT 86235
Hospital Charge Code	4000067
Hospital Revenue Code	300
Min. Negotiated Rate	$79.80
Max. Negotiated Rate	$114.00
Rate for Payer: Aetna Commercial	$108.30
Rate for Payer: Aetna Medicare	$102.60
Rate for Payer: BCBS MT CHIP	$102.60
Rate for Payer: BCBS MT Closed Plan Network	$108.30
Rate for Payer: BCBS MT HealthLink	$102.60
Rate for Payer: BCBS MT Medicare	$102.60
Rate for Payer: BCBS MT POS	$108.30
Rate for Payer: BCBS MT Traditional	$114.00
Rate for Payer: Cash Price	$102.60
Rate for Payer: Cigna Commercial	$108.30
Rate for Payer: Cigna Medicare	$102.60
Rate for Payer: Medicaid All Medicaid	$104.88
Rate for Payer: Medicare All Medicare	$79.80
Rate for Payer: Monida Allegiance	$108.30
Rate for Payer: Monida First Choice Health	$110.58
Rate for Payer: Monida Montana Health Co-op	$108.30
Rate for Payer: Monida PacificSource	$108.30

ST ASSESS APHASIA W/REPORT

Facility

$311.00

Service Code	CPT 96105
Hospital Charge Code	6396105
Hospital Revenue Code	440
Min. Negotiated Rate	$217.70
Max. Negotiated Rate	$311.00
Rate for Payer: Aetna Commercial	$295.45
Rate for Payer: Aetna Medicare	$279.90
Rate for Payer: BCBS MT CHIP	$279.90
Rate for Payer: BCBS MT Closed Plan Network	$295.45
Rate for Payer: BCBS MT HealthLink	$279.90
Rate for Payer: BCBS MT Medicare	$279.90
Rate for Payer: BCBS MT POS	$295.45
Rate for Payer: BCBS MT Traditional	$311.00
Rate for Payer: Cash Price	$279.90
Rate for Payer: Cigna Commercial	$295.45
Rate for Payer: Cigna Medicare	$279.90
Rate for Payer: Medicaid All Medicaid	$286.12
Rate for Payer: Medicare All Medicare	$217.70
Rate for Payer: Monida Allegiance	$295.45
Rate for Payer: Monida First Choice Health	$301.67
Rate for Payer: Monida Montana Health Co-op	$295.45
Rate for Payer: Monida PacificSource	$295.45

ST ASSESS APHASIA W/REPORT

Facility

$311.00

Service Code	CPT 96105
Hospital Charge Code	6396105
Hospital Revenue Code	440
Min. Negotiated Rate	$217.70
Max. Negotiated Rate	$311.00
Rate for Payer: Aetna Commercial	$295.45
Rate for Payer: Aetna Medicare	$279.90
Rate for Payer: BCBS MT CHIP	$279.90
Rate for Payer: BCBS MT Closed Plan Network	$295.45
Rate for Payer: BCBS MT HealthLink	$279.90
Rate for Payer: BCBS MT Medicare	$279.90
Rate for Payer: BCBS MT POS	$295.45
Rate for Payer: BCBS MT Traditional	$311.00
Rate for Payer: Cash Price	$279.90
Rate for Payer: Cigna Commercial	$295.45
Rate for Payer: Cigna Medicare	$279.90
Rate for Payer: Medicaid All Medicaid	$286.12
Rate for Payer: Medicare All Medicare	$217.70
Rate for Payer: Monida Allegiance	$295.45
Rate for Payer: Monida First Choice Health	$301.67
Rate for Payer: Monida Montana Health Co-op	$295.45
Rate for Payer: Monida PacificSource	$295.45

ST BEHAVIORAL AND QUALITATIVE ANALYSIS

Facility

$282.00

Service Code	CPT 92524
Hospital Charge Code	6392524
Hospital Revenue Code	440
Min. Negotiated Rate	$197.40
Max. Negotiated Rate	$282.00
Rate for Payer: Aetna Commercial	$267.90
Rate for Payer: Aetna Medicare	$253.80
Rate for Payer: BCBS MT CHIP	$253.80
Rate for Payer: BCBS MT Closed Plan Network	$267.90
Rate for Payer: BCBS MT HealthLink	$253.80
Rate for Payer: BCBS MT Medicare	$253.80
Rate for Payer: BCBS MT POS	$267.90
Rate for Payer: BCBS MT Traditional	$282.00
Rate for Payer: Cash Price	$253.80
Rate for Payer: Cigna Commercial	$267.90
Rate for Payer: Cigna Medicare	$253.80
Rate for Payer: Medicaid All Medicaid	$259.44
Rate for Payer: Medicare All Medicare	$197.40
Rate for Payer: Monida Allegiance	$267.90
Rate for Payer: Monida First Choice Health	$273.54
Rate for Payer: Monida Montana Health Co-op	$267.90
Rate for Payer: Monida PacificSource	$267.90

ST BEHAVIORAL AND QUALITATIVE ANALYSIS

Facility

$282.00

Service Code	CPT 92524
Hospital Charge Code	6392524
Hospital Revenue Code	440
Min. Negotiated Rate	$197.40
Max. Negotiated Rate	$282.00
Rate for Payer: Aetna Commercial	$267.90
Rate for Payer: Aetna Medicare	$253.80
Rate for Payer: BCBS MT CHIP	$253.80
Rate for Payer: BCBS MT Closed Plan Network	$267.90
Rate for Payer: BCBS MT HealthLink	$253.80
Rate for Payer: BCBS MT Medicare	$253.80
Rate for Payer: BCBS MT POS	$267.90
Rate for Payer: BCBS MT Traditional	$282.00
Rate for Payer: Cash Price	$253.80
Rate for Payer: Cigna Commercial	$267.90
Rate for Payer: Cigna Medicare	$253.80
Rate for Payer: Medicaid All Medicaid	$259.44
Rate for Payer: Medicare All Medicare	$197.40
Rate for Payer: Monida Allegiance	$267.90
Rate for Payer: Monida First Choice Health	$273.54
Rate for Payer: Monida Montana Health Co-op	$267.90
Rate for Payer: Monida PacificSource	$267.90

Know your out-of-pocket cost for care.

All Charges