Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

ST DEVELOPMENTAL TESTING LIMITED

Facility

$34.00

Service Code	CPT 96110
Hospital Charge Code	6396110
Hospital Revenue Code	440
Min. Negotiated Rate	$23.80
Max. Negotiated Rate	$34.00
Rate for Payer: Aetna Commercial	$32.30
Rate for Payer: Aetna Medicare	$30.60
Rate for Payer: BCBS MT CHIP	$30.60
Rate for Payer: BCBS MT Closed Plan Network	$32.30
Rate for Payer: BCBS MT HealthLink	$30.60
Rate for Payer: BCBS MT Medicare	$30.60
Rate for Payer: BCBS MT POS	$32.30
Rate for Payer: BCBS MT Traditional	$34.00
Rate for Payer: Cash Price	$30.60
Rate for Payer: Cigna Commercial	$32.30
Rate for Payer: Cigna Medicare	$30.60
Rate for Payer: Medicaid All Medicaid	$31.28
Rate for Payer: Medicare All Medicare	$23.80
Rate for Payer: Monida Allegiance	$32.30
Rate for Payer: Monida First Choice Health	$32.98
Rate for Payer: Monida Montana Health Co-op	$32.30
Rate for Payer: Monida PacificSource	$32.30

ST DEVELOPMENTAL TESTING LIMITED

Facility

$34.00

Service Code	CPT 96110
Hospital Charge Code	6396110
Hospital Revenue Code	440
Min. Negotiated Rate	$23.80
Max. Negotiated Rate	$34.00
Rate for Payer: Aetna Commercial	$32.30
Rate for Payer: Aetna Medicare	$30.60
Rate for Payer: BCBS MT CHIP	$30.60
Rate for Payer: BCBS MT Closed Plan Network	$32.30
Rate for Payer: BCBS MT HealthLink	$30.60
Rate for Payer: BCBS MT Medicare	$30.60
Rate for Payer: BCBS MT POS	$32.30
Rate for Payer: BCBS MT Traditional	$34.00
Rate for Payer: Cash Price	$30.60
Rate for Payer: Cigna Commercial	$32.30
Rate for Payer: Cigna Medicare	$30.60
Rate for Payer: Medicaid All Medicaid	$31.28
Rate for Payer: Medicare All Medicare	$23.80
Rate for Payer: Monida Allegiance	$32.30
Rate for Payer: Monida First Choice Health	$32.98
Rate for Payer: Monida Montana Health Co-op	$32.30
Rate for Payer: Monida PacificSource	$32.30

STERILE TOWEL DRAPE (FENESTRAT

Facility

$20.00

Hospital Charge Code	80030489
Hospital Revenue Code	270
Min. Negotiated Rate	$14.00
Max. Negotiated Rate	$20.00
Rate for Payer: Aetna Commercial	$19.00
Rate for Payer: Aetna Medicare	$18.00
Rate for Payer: BCBS MT CHIP	$18.00
Rate for Payer: BCBS MT Closed Plan Network	$19.00
Rate for Payer: BCBS MT HealthLink	$18.00
Rate for Payer: BCBS MT Medicare	$18.00
Rate for Payer: BCBS MT POS	$19.00
Rate for Payer: BCBS MT Traditional	$20.00
Rate for Payer: Cash Price	$18.00
Rate for Payer: Cigna Commercial	$19.00
Rate for Payer: Cigna Medicare	$18.00
Rate for Payer: Medicaid All Medicaid	$18.40
Rate for Payer: Medicare All Medicare	$14.00
Rate for Payer: Monida Allegiance	$19.00
Rate for Payer: Monida First Choice Health	$19.40
Rate for Payer: Monida Montana Health Co-op	$19.00
Rate for Payer: Monida PacificSource	$19.00

STERILE TOWEL DRAPE (FENESTRAT

Facility

$20.00

Hospital Charge Code	80030489
Hospital Revenue Code	270
Min. Negotiated Rate	$14.00
Max. Negotiated Rate	$20.00
Rate for Payer: Aetna Commercial	$19.00
Rate for Payer: Aetna Medicare	$18.00
Rate for Payer: BCBS MT CHIP	$18.00
Rate for Payer: BCBS MT Closed Plan Network	$19.00
Rate for Payer: BCBS MT HealthLink	$18.00
Rate for Payer: BCBS MT Medicare	$18.00
Rate for Payer: BCBS MT POS	$19.00
Rate for Payer: BCBS MT Traditional	$20.00
Rate for Payer: Cash Price	$18.00
Rate for Payer: Cigna Commercial	$19.00
Rate for Payer: Cigna Medicare	$18.00
Rate for Payer: Medicaid All Medicaid	$18.40
Rate for Payer: Medicare All Medicare	$14.00
Rate for Payer: Monida Allegiance	$19.00
Rate for Payer: Monida First Choice Health	$19.40
Rate for Payer: Monida Montana Health Co-op	$19.00
Rate for Payer: Monida PacificSource	$19.00

STERILE TOWEL DRAPE (PLAIN)

Facility

$4.00

Hospital Charge Code	80030488
Hospital Revenue Code	270
Min. Negotiated Rate	$2.80
Max. Negotiated Rate	$4.00
Rate for Payer: Aetna Commercial	$3.80
Rate for Payer: Aetna Medicare	$3.60
Rate for Payer: BCBS MT CHIP	$3.60
Rate for Payer: BCBS MT Closed Plan Network	$3.80
Rate for Payer: BCBS MT HealthLink	$3.60
Rate for Payer: BCBS MT Medicare	$3.60
Rate for Payer: BCBS MT POS	$3.80
Rate for Payer: BCBS MT Traditional	$4.00
Rate for Payer: Cash Price	$3.60
Rate for Payer: Cigna Commercial	$3.80
Rate for Payer: Cigna Medicare	$3.60
Rate for Payer: Medicaid All Medicaid	$3.68
Rate for Payer: Medicare All Medicare	$2.80
Rate for Payer: Monida Allegiance	$3.80
Rate for Payer: Monida First Choice Health	$3.88
Rate for Payer: Monida Montana Health Co-op	$3.80
Rate for Payer: Monida PacificSource	$3.80

STERILE TOWEL DRAPE (PLAIN)

Facility

$4.00

Hospital Charge Code	80030488
Hospital Revenue Code	270
Min. Negotiated Rate	$2.80
Max. Negotiated Rate	$4.00
Rate for Payer: Aetna Commercial	$3.80
Rate for Payer: Aetna Medicare	$3.60
Rate for Payer: BCBS MT CHIP	$3.60
Rate for Payer: BCBS MT Closed Plan Network	$3.80
Rate for Payer: BCBS MT HealthLink	$3.60
Rate for Payer: BCBS MT Medicare	$3.60
Rate for Payer: BCBS MT POS	$3.80
Rate for Payer: BCBS MT Traditional	$4.00
Rate for Payer: Cash Price	$3.60
Rate for Payer: Cigna Commercial	$3.80
Rate for Payer: Cigna Medicare	$3.60
Rate for Payer: Medicaid All Medicaid	$3.68
Rate for Payer: Medicare All Medicare	$2.80
Rate for Payer: Monida Allegiance	$3.80
Rate for Payer: Monida First Choice Health	$3.88
Rate for Payer: Monida Montana Health Co-op	$3.80
Rate for Payer: Monida PacificSource	$3.80

STERISTRIPS 1/4X4

Facility

$21.00

Hospital Charge Code	80030414
Hospital Revenue Code	270
Min. Negotiated Rate	$14.70
Max. Negotiated Rate	$21.00
Rate for Payer: Aetna Commercial	$19.95
Rate for Payer: Aetna Medicare	$18.90
Rate for Payer: BCBS MT CHIP	$18.90
Rate for Payer: BCBS MT Closed Plan Network	$19.95
Rate for Payer: BCBS MT HealthLink	$18.90
Rate for Payer: BCBS MT Medicare	$18.90
Rate for Payer: BCBS MT POS	$19.95
Rate for Payer: BCBS MT Traditional	$21.00
Rate for Payer: Cash Price	$18.90
Rate for Payer: Cigna Commercial	$19.95
Rate for Payer: Cigna Medicare	$18.90
Rate for Payer: Medicaid All Medicaid	$19.32
Rate for Payer: Medicare All Medicare	$14.70
Rate for Payer: Monida Allegiance	$19.95
Rate for Payer: Monida First Choice Health	$20.37
Rate for Payer: Monida Montana Health Co-op	$19.95
Rate for Payer: Monida PacificSource	$19.95

STERISTRIPS 1/4X4

Facility

$21.00

Hospital Charge Code	80030414
Hospital Revenue Code	270
Min. Negotiated Rate	$14.70
Max. Negotiated Rate	$21.00
Rate for Payer: Aetna Commercial	$19.95
Rate for Payer: Aetna Medicare	$18.90
Rate for Payer: BCBS MT CHIP	$18.90
Rate for Payer: BCBS MT Closed Plan Network	$19.95
Rate for Payer: BCBS MT HealthLink	$18.90
Rate for Payer: BCBS MT Medicare	$18.90
Rate for Payer: BCBS MT POS	$19.95
Rate for Payer: BCBS MT Traditional	$21.00
Rate for Payer: Cash Price	$18.90
Rate for Payer: Cigna Commercial	$19.95
Rate for Payer: Cigna Medicare	$18.90
Rate for Payer: Medicaid All Medicaid	$19.32
Rate for Payer: Medicare All Medicare	$14.70
Rate for Payer: Monida Allegiance	$19.95
Rate for Payer: Monida First Choice Health	$20.37
Rate for Payer: Monida Montana Health Co-op	$19.95
Rate for Payer: Monida PacificSource	$19.95

ST EVAL OF ORAL&PHARYNGEAL SWALLOWING F

Facility

$677.00

Service Code	CPT 92610
Hospital Charge Code	6392610
Hospital Revenue Code	440
Min. Negotiated Rate	$473.90
Max. Negotiated Rate	$677.00
Rate for Payer: Aetna Commercial	$643.15
Rate for Payer: Aetna Medicare	$609.30
Rate for Payer: BCBS MT CHIP	$609.30
Rate for Payer: BCBS MT Closed Plan Network	$643.15
Rate for Payer: BCBS MT HealthLink	$609.30
Rate for Payer: BCBS MT Medicare	$609.30
Rate for Payer: BCBS MT POS	$643.15
Rate for Payer: BCBS MT Traditional	$677.00
Rate for Payer: Cash Price	$609.30
Rate for Payer: Cigna Commercial	$643.15
Rate for Payer: Cigna Medicare	$609.30
Rate for Payer: Medicaid All Medicaid	$622.84
Rate for Payer: Medicare All Medicare	$473.90
Rate for Payer: Monida Allegiance	$643.15
Rate for Payer: Monida First Choice Health	$656.69
Rate for Payer: Monida Montana Health Co-op	$643.15
Rate for Payer: Monida PacificSource	$643.15

ST EVAL OF ORAL&PHARYNGEAL SWALLOWING F

Facility

$677.00

Service Code	CPT 92610
Hospital Charge Code	6392610
Hospital Revenue Code	440
Min. Negotiated Rate	$473.90
Max. Negotiated Rate	$677.00
Rate for Payer: Aetna Commercial	$643.15
Rate for Payer: Aetna Medicare	$609.30
Rate for Payer: BCBS MT CHIP	$609.30
Rate for Payer: BCBS MT Closed Plan Network	$643.15
Rate for Payer: BCBS MT HealthLink	$609.30
Rate for Payer: BCBS MT Medicare	$609.30
Rate for Payer: BCBS MT POS	$643.15
Rate for Payer: BCBS MT Traditional	$677.00
Rate for Payer: Cash Price	$609.30
Rate for Payer: Cigna Commercial	$643.15
Rate for Payer: Cigna Medicare	$609.30
Rate for Payer: Medicaid All Medicaid	$622.84
Rate for Payer: Medicare All Medicare	$473.90
Rate for Payer: Monida Allegiance	$643.15
Rate for Payer: Monida First Choice Health	$656.69
Rate for Payer: Monida Montana Health Co-op	$643.15
Rate for Payer: Monida PacificSource	$643.15

ST EVAL SPEECH FLUENCY(STUTTERING CLUTT

Facility

$352.00

Service Code	CPT 92521
Hospital Charge Code	6392521
Hospital Revenue Code	440
Min. Negotiated Rate	$246.40
Max. Negotiated Rate	$352.00
Rate for Payer: Aetna Commercial	$334.40
Rate for Payer: Aetna Medicare	$316.80
Rate for Payer: BCBS MT CHIP	$316.80
Rate for Payer: BCBS MT Closed Plan Network	$334.40
Rate for Payer: BCBS MT HealthLink	$316.80
Rate for Payer: BCBS MT Medicare	$316.80
Rate for Payer: BCBS MT POS	$334.40
Rate for Payer: BCBS MT Traditional	$352.00
Rate for Payer: Cash Price	$316.80
Rate for Payer: Cigna Commercial	$334.40
Rate for Payer: Cigna Medicare	$316.80
Rate for Payer: Medicaid All Medicaid	$323.84
Rate for Payer: Medicare All Medicare	$246.40
Rate for Payer: Monida Allegiance	$334.40
Rate for Payer: Monida First Choice Health	$341.44
Rate for Payer: Monida Montana Health Co-op	$334.40
Rate for Payer: Monida PacificSource	$334.40

ST EVAL SPEECH FLUENCY(STUTTERING CLUTT

Facility

$352.00

Service Code	CPT 92521
Hospital Charge Code	6392521
Hospital Revenue Code	440
Min. Negotiated Rate	$246.40
Max. Negotiated Rate	$352.00
Rate for Payer: Aetna Commercial	$334.40
Rate for Payer: Aetna Medicare	$316.80
Rate for Payer: BCBS MT CHIP	$316.80
Rate for Payer: BCBS MT Closed Plan Network	$334.40
Rate for Payer: BCBS MT HealthLink	$316.80
Rate for Payer: BCBS MT Medicare	$316.80
Rate for Payer: BCBS MT POS	$334.40
Rate for Payer: BCBS MT Traditional	$352.00
Rate for Payer: Cash Price	$316.80
Rate for Payer: Cigna Commercial	$334.40
Rate for Payer: Cigna Medicare	$316.80
Rate for Payer: Medicaid All Medicaid	$323.84
Rate for Payer: Medicare All Medicare	$246.40
Rate for Payer: Monida Allegiance	$334.40
Rate for Payer: Monida First Choice Health	$341.44
Rate for Payer: Monida Montana Health Co-op	$334.40
Rate for Payer: Monida PacificSource	$334.40

ST EVAL SPEECH SOUND PROD LANGUAGE

Facility

$352.00

Service Code	CPT 92523
Hospital Charge Code	6392523
Hospital Revenue Code	440
Min. Negotiated Rate	$246.40
Max. Negotiated Rate	$352.00
Rate for Payer: Aetna Commercial	$334.40
Rate for Payer: Aetna Medicare	$316.80
Rate for Payer: BCBS MT CHIP	$316.80
Rate for Payer: BCBS MT Closed Plan Network	$334.40
Rate for Payer: BCBS MT HealthLink	$316.80
Rate for Payer: BCBS MT Medicare	$316.80
Rate for Payer: BCBS MT POS	$334.40
Rate for Payer: BCBS MT Traditional	$352.00
Rate for Payer: Cash Price	$316.80
Rate for Payer: Cigna Commercial	$334.40
Rate for Payer: Cigna Medicare	$316.80
Rate for Payer: Medicaid All Medicaid	$323.84
Rate for Payer: Medicare All Medicare	$246.40
Rate for Payer: Monida Allegiance	$334.40
Rate for Payer: Monida First Choice Health	$341.44
Rate for Payer: Monida Montana Health Co-op	$334.40
Rate for Payer: Monida PacificSource	$334.40

ST EVAL SPEECH SOUND PROD LANGUAGE

Facility

$352.00

Service Code	CPT 92523
Hospital Charge Code	6392523
Hospital Revenue Code	440
Min. Negotiated Rate	$246.40
Max. Negotiated Rate	$352.00
Rate for Payer: Aetna Commercial	$334.40
Rate for Payer: Aetna Medicare	$316.80
Rate for Payer: BCBS MT CHIP	$316.80
Rate for Payer: BCBS MT Closed Plan Network	$334.40
Rate for Payer: BCBS MT HealthLink	$316.80
Rate for Payer: BCBS MT Medicare	$316.80
Rate for Payer: BCBS MT POS	$334.40
Rate for Payer: BCBS MT Traditional	$352.00
Rate for Payer: Cash Price	$316.80
Rate for Payer: Cigna Commercial	$334.40
Rate for Payer: Cigna Medicare	$316.80
Rate for Payer: Medicaid All Medicaid	$323.84
Rate for Payer: Medicare All Medicare	$246.40
Rate for Payer: Monida Allegiance	$334.40
Rate for Payer: Monida First Choice Health	$341.44
Rate for Payer: Monida Montana Health Co-op	$334.40
Rate for Payer: Monida PacificSource	$334.40

ST EVAL SPEECH SOUND PRODUCTION

Facility

$352.00

Service Code	CPT 92522
Hospital Charge Code	6392522
Hospital Revenue Code	440
Min. Negotiated Rate	$246.40
Max. Negotiated Rate	$352.00
Rate for Payer: Aetna Commercial	$334.40
Rate for Payer: Aetna Medicare	$316.80
Rate for Payer: BCBS MT CHIP	$316.80
Rate for Payer: BCBS MT Closed Plan Network	$334.40
Rate for Payer: BCBS MT HealthLink	$316.80
Rate for Payer: BCBS MT Medicare	$316.80
Rate for Payer: BCBS MT POS	$334.40
Rate for Payer: BCBS MT Traditional	$352.00
Rate for Payer: Cash Price	$316.80
Rate for Payer: Cigna Commercial	$334.40
Rate for Payer: Cigna Medicare	$316.80
Rate for Payer: Medicaid All Medicaid	$323.84
Rate for Payer: Medicare All Medicare	$246.40
Rate for Payer: Monida Allegiance	$334.40
Rate for Payer: Monida First Choice Health	$341.44
Rate for Payer: Monida Montana Health Co-op	$334.40
Rate for Payer: Monida PacificSource	$334.40

ST EVAL SPEECH SOUND PRODUCTION

Facility

$352.00

Service Code	CPT 92522
Hospital Charge Code	6392522
Hospital Revenue Code	440
Min. Negotiated Rate	$246.40
Max. Negotiated Rate	$352.00
Rate for Payer: Aetna Commercial	$334.40
Rate for Payer: Aetna Medicare	$316.80
Rate for Payer: BCBS MT CHIP	$316.80
Rate for Payer: BCBS MT Closed Plan Network	$334.40
Rate for Payer: BCBS MT HealthLink	$316.80
Rate for Payer: BCBS MT Medicare	$316.80
Rate for Payer: BCBS MT POS	$334.40
Rate for Payer: BCBS MT Traditional	$352.00
Rate for Payer: Cash Price	$316.80
Rate for Payer: Cigna Commercial	$334.40
Rate for Payer: Cigna Medicare	$316.80
Rate for Payer: Medicaid All Medicaid	$323.84
Rate for Payer: Medicare All Medicare	$246.40
Rate for Payer: Monida Allegiance	$334.40
Rate for Payer: Monida First Choice Health	$341.44
Rate for Payer: Monida Montana Health Co-op	$334.40
Rate for Payer: Monida PacificSource	$334.40

ST EVAL VOICE PROSTH/AUG COMM

Facility

$385.00

Service Code	CPT 92597
Hospital Charge Code	6392597
Hospital Revenue Code	440
Min. Negotiated Rate	$269.50
Max. Negotiated Rate	$385.00
Rate for Payer: Aetna Commercial	$365.75
Rate for Payer: Aetna Medicare	$346.50
Rate for Payer: BCBS MT CHIP	$346.50
Rate for Payer: BCBS MT Closed Plan Network	$365.75
Rate for Payer: BCBS MT HealthLink	$346.50
Rate for Payer: BCBS MT Medicare	$346.50
Rate for Payer: BCBS MT POS	$365.75
Rate for Payer: BCBS MT Traditional	$385.00
Rate for Payer: Cash Price	$346.50
Rate for Payer: Cigna Commercial	$365.75
Rate for Payer: Cigna Medicare	$346.50
Rate for Payer: Medicaid All Medicaid	$354.20
Rate for Payer: Medicare All Medicare	$269.50
Rate for Payer: Monida Allegiance	$365.75
Rate for Payer: Monida First Choice Health	$373.45
Rate for Payer: Monida Montana Health Co-op	$365.75
Rate for Payer: Monida PacificSource	$365.75

ST EVAL VOICE PROSTH/AUG COMM

Facility

$385.00

Service Code	CPT 92597
Hospital Charge Code	6392597
Hospital Revenue Code	440
Min. Negotiated Rate	$269.50
Max. Negotiated Rate	$385.00
Rate for Payer: Aetna Commercial	$365.75
Rate for Payer: Aetna Medicare	$346.50
Rate for Payer: BCBS MT CHIP	$346.50
Rate for Payer: BCBS MT Closed Plan Network	$365.75
Rate for Payer: BCBS MT HealthLink	$346.50
Rate for Payer: BCBS MT Medicare	$346.50
Rate for Payer: BCBS MT POS	$365.75
Rate for Payer: BCBS MT Traditional	$385.00
Rate for Payer: Cash Price	$346.50
Rate for Payer: Cigna Commercial	$365.75
Rate for Payer: Cigna Medicare	$346.50
Rate for Payer: Medicaid All Medicaid	$354.20
Rate for Payer: Medicare All Medicare	$269.50
Rate for Payer: Monida Allegiance	$365.75
Rate for Payer: Monida First Choice Health	$373.45
Rate for Payer: Monida Montana Health Co-op	$365.75
Rate for Payer: Monida PacificSource	$365.75

ST GROUP THERAPEUTIC PROC

Facility

$95.00

Service Code	CPT 97150
Hospital Charge Code	6397150
Hospital Revenue Code	440
Min. Negotiated Rate	$66.50
Max. Negotiated Rate	$95.00
Rate for Payer: Aetna Commercial	$90.25
Rate for Payer: Aetna Medicare	$85.50
Rate for Payer: BCBS MT CHIP	$85.50
Rate for Payer: BCBS MT Closed Plan Network	$90.25
Rate for Payer: BCBS MT HealthLink	$85.50
Rate for Payer: BCBS MT Medicare	$85.50
Rate for Payer: BCBS MT POS	$90.25
Rate for Payer: BCBS MT Traditional	$95.00
Rate for Payer: Cash Price	$85.50
Rate for Payer: Cigna Commercial	$90.25
Rate for Payer: Cigna Medicare	$85.50
Rate for Payer: Medicaid All Medicaid	$87.40
Rate for Payer: Medicare All Medicare	$66.50
Rate for Payer: Monida Allegiance	$90.25
Rate for Payer: Monida First Choice Health	$92.15
Rate for Payer: Monida Montana Health Co-op	$90.25
Rate for Payer: Monida PacificSource	$90.25

ST GROUP THERAPEUTIC PROC

Facility

$95.00

Service Code	CPT 97150
Hospital Charge Code	6397150
Hospital Revenue Code	440
Min. Negotiated Rate	$66.50
Max. Negotiated Rate	$95.00
Rate for Payer: Aetna Commercial	$90.25
Rate for Payer: Aetna Medicare	$85.50
Rate for Payer: BCBS MT CHIP	$85.50
Rate for Payer: BCBS MT Closed Plan Network	$90.25
Rate for Payer: BCBS MT HealthLink	$85.50
Rate for Payer: BCBS MT Medicare	$85.50
Rate for Payer: BCBS MT POS	$90.25
Rate for Payer: BCBS MT Traditional	$95.00
Rate for Payer: Cash Price	$85.50
Rate for Payer: Cigna Commercial	$90.25
Rate for Payer: Cigna Medicare	$85.50
Rate for Payer: Medicaid All Medicaid	$87.40
Rate for Payer: Medicare All Medicare	$66.50
Rate for Payer: Monida Allegiance	$90.25
Rate for Payer: Monida First Choice Health	$92.15
Rate for Payer: Monida Montana Health Co-op	$90.25
Rate for Payer: Monida PacificSource	$90.25

STIOLTO RESP INH [2.5 MCG/2.5 MCG] NF

Facility

$987.00

Service Code	HCPCS J8499
Hospital Charge Code	3007698
Hospital Revenue Code	250
Min. Negotiated Rate	$690.90
Max. Negotiated Rate	$987.00
Rate for Payer: Aetna Commercial	$937.65
Rate for Payer: Aetna Medicare	$888.30
Rate for Payer: BCBS MT CHIP	$888.30
Rate for Payer: BCBS MT Closed Plan Network	$937.65
Rate for Payer: BCBS MT HealthLink	$888.30
Rate for Payer: BCBS MT Medicare	$888.30
Rate for Payer: BCBS MT POS	$937.65
Rate for Payer: BCBS MT Traditional	$987.00
Rate for Payer: Cash Price	$888.30
Rate for Payer: Cigna Commercial	$937.65
Rate for Payer: Cigna Medicare	$888.30
Rate for Payer: Medicaid All Medicaid	$908.04
Rate for Payer: Medicare All Medicare	$690.90
Rate for Payer: Monida Allegiance	$937.65
Rate for Payer: Monida First Choice Health	$957.39
Rate for Payer: Monida Montana Health Co-op	$937.65
Rate for Payer: Monida PacificSource	$937.65

STIOLTO RESP INH [2.5 MCG/2.5 MCG] NF

Facility

$987.00

Service Code	HCPCS J8499
Hospital Charge Code	3007698
Hospital Revenue Code	250
Min. Negotiated Rate	$690.90
Max. Negotiated Rate	$987.00
Rate for Payer: Aetna Commercial	$937.65
Rate for Payer: Aetna Medicare	$888.30
Rate for Payer: BCBS MT CHIP	$888.30
Rate for Payer: BCBS MT Closed Plan Network	$937.65
Rate for Payer: BCBS MT HealthLink	$888.30
Rate for Payer: BCBS MT Medicare	$888.30
Rate for Payer: BCBS MT POS	$937.65
Rate for Payer: BCBS MT Traditional	$987.00
Rate for Payer: Cash Price	$888.30
Rate for Payer: Cigna Commercial	$937.65
Rate for Payer: Cigna Medicare	$888.30
Rate for Payer: Medicaid All Medicaid	$908.04
Rate for Payer: Medicare All Medicare	$690.90
Rate for Payer: Monida Allegiance	$937.65
Rate for Payer: Monida First Choice Health	$957.39
Rate for Payer: Monida Montana Health Co-op	$937.65
Rate for Payer: Monida PacificSource	$937.65

ST NEUROMUSCULAR RE-ED

Facility

$112.00

Service Code	CPT 97112
Hospital Charge Code	6397112
Hospital Revenue Code	440
Min. Negotiated Rate	$78.40
Max. Negotiated Rate	$112.00
Rate for Payer: Aetna Commercial	$106.40
Rate for Payer: Aetna Medicare	$100.80
Rate for Payer: BCBS MT CHIP	$100.80
Rate for Payer: BCBS MT Closed Plan Network	$106.40
Rate for Payer: BCBS MT HealthLink	$100.80
Rate for Payer: BCBS MT Medicare	$100.80
Rate for Payer: BCBS MT POS	$106.40
Rate for Payer: BCBS MT Traditional	$112.00
Rate for Payer: Cash Price	$100.80
Rate for Payer: Cigna Commercial	$106.40
Rate for Payer: Cigna Medicare	$100.80
Rate for Payer: Medicaid All Medicaid	$103.04
Rate for Payer: Medicare All Medicare	$78.40
Rate for Payer: Monida Allegiance	$106.40
Rate for Payer: Monida First Choice Health	$108.64
Rate for Payer: Monida Montana Health Co-op	$106.40
Rate for Payer: Monida PacificSource	$106.40

ST NEUROMUSCULAR RE-ED

Facility

$112.00

Service Code	CPT 97112
Hospital Charge Code	6397112
Hospital Revenue Code	440
Min. Negotiated Rate	$78.40
Max. Negotiated Rate	$112.00
Rate for Payer: Aetna Commercial	$106.40
Rate for Payer: Aetna Medicare	$100.80
Rate for Payer: BCBS MT CHIP	$100.80
Rate for Payer: BCBS MT Closed Plan Network	$106.40
Rate for Payer: BCBS MT HealthLink	$100.80
Rate for Payer: BCBS MT Medicare	$100.80
Rate for Payer: BCBS MT POS	$106.40
Rate for Payer: BCBS MT Traditional	$112.00
Rate for Payer: Cash Price	$100.80
Rate for Payer: Cigna Commercial	$106.40
Rate for Payer: Cigna Medicare	$100.80
Rate for Payer: Medicaid All Medicaid	$103.04
Rate for Payer: Medicare All Medicare	$78.40
Rate for Payer: Monida Allegiance	$106.40
Rate for Payer: Monida First Choice Health	$108.64
Rate for Payer: Monida Montana Health Co-op	$106.40
Rate for Payer: Monida PacificSource	$106.40

ST OFC/OUT-PT FOR EVAL/MGMT

Professional

Both

$159.00

Service Code	CPT 99202
Hospital Charge Code	6399202
Hospital Revenue Code	979
Min. Negotiated Rate	$111.30
Max. Negotiated Rate	$154.23
Rate for Payer: Aetna Commercial	$151.05
Rate for Payer: Aetna Medicare	$143.10
Rate for Payer: Cash Price	$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

Know your out-of-pocket cost for care.

All Charges