Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

SYNCH AUDIO-ONLY NEW HIGH 60

Facility

$301.00

Service Code	CPT 98011
Hospital Charge Code	8098011
Hospital Revenue Code	521
Min. Negotiated Rate	$210.70
Max. Negotiated Rate	$301.00
Rate for Payer: Aetna Commercial	$285.95
Rate for Payer: Aetna Medicare	$270.90
Rate for Payer: BCBS MT CHIP	$270.90
Rate for Payer: BCBS MT Closed Plan Network	$285.95
Rate for Payer: BCBS MT HealthLink	$270.90
Rate for Payer: BCBS MT Medicare	$270.90
Rate for Payer: BCBS MT POS	$285.95
Rate for Payer: BCBS MT Traditional	$301.00
Rate for Payer: Cash Price	$270.90
Rate for Payer: Cigna Commercial	$285.95
Rate for Payer: Cigna Medicare	$270.90
Rate for Payer: Medicaid All Medicaid	$276.92
Rate for Payer: Medicare All Medicare	$210.70
Rate for Payer: Monida Allegiance	$285.95
Rate for Payer: Monida First Choice Health	$291.97
Rate for Payer: Monida Montana Health Co-op	$285.95
Rate for Payer: Monida PacificSource	$285.95

SYNCH AUDIO-ONLY NEW LOW 30

Facility

$145.00

Service Code	CPT 98009
Hospital Charge Code	8098009
Hospital Revenue Code	521
Min. Negotiated Rate	$101.50
Max. Negotiated Rate	$145.00
Rate for Payer: Aetna Commercial	$137.75
Rate for Payer: Aetna Medicare	$130.50
Rate for Payer: BCBS MT CHIP	$130.50
Rate for Payer: BCBS MT Closed Plan Network	$137.75
Rate for Payer: BCBS MT HealthLink	$130.50
Rate for Payer: BCBS MT Medicare	$130.50
Rate for Payer: BCBS MT POS	$137.75
Rate for Payer: BCBS MT Traditional	$145.00
Rate for Payer: Cash Price	$130.50
Rate for Payer: Cigna Commercial	$137.75
Rate for Payer: Cigna Medicare	$130.50
Rate for Payer: Medicaid All Medicaid	$133.40
Rate for Payer: Medicare All Medicare	$101.50
Rate for Payer: Monida Allegiance	$137.75
Rate for Payer: Monida First Choice Health	$140.65
Rate for Payer: Monida Montana Health Co-op	$137.75
Rate for Payer: Monida PacificSource	$137.75

SYNCH AUDIO-ONLY NEW LOW 30

Facility

$145.00

Service Code	CPT 98009
Hospital Charge Code	8098009
Hospital Revenue Code	521
Min. Negotiated Rate	$101.50
Max. Negotiated Rate	$145.00
Rate for Payer: Aetna Commercial	$137.75
Rate for Payer: Aetna Medicare	$130.50
Rate for Payer: BCBS MT CHIP	$130.50
Rate for Payer: BCBS MT Closed Plan Network	$137.75
Rate for Payer: BCBS MT HealthLink	$130.50
Rate for Payer: BCBS MT Medicare	$130.50
Rate for Payer: BCBS MT POS	$137.75
Rate for Payer: BCBS MT Traditional	$145.00
Rate for Payer: Cash Price	$130.50
Rate for Payer: Cigna Commercial	$137.75
Rate for Payer: Cigna Medicare	$130.50
Rate for Payer: Medicaid All Medicaid	$133.40
Rate for Payer: Medicare All Medicare	$101.50
Rate for Payer: Monida Allegiance	$137.75
Rate for Payer: Monida First Choice Health	$140.65
Rate for Payer: Monida Montana Health Co-op	$137.75
Rate for Payer: Monida PacificSource	$137.75

SYNCH AUDIO-ONLY NEW MOD 45

Facility

$229.00

Service Code	CPT 98010
Hospital Charge Code	8098010
Hospital Revenue Code	521
Min. Negotiated Rate	$160.30
Max. Negotiated Rate	$229.00
Rate for Payer: Aetna Commercial	$217.55
Rate for Payer: Aetna Medicare	$206.10
Rate for Payer: BCBS MT CHIP	$206.10
Rate for Payer: BCBS MT Closed Plan Network	$217.55
Rate for Payer: BCBS MT HealthLink	$206.10
Rate for Payer: BCBS MT Medicare	$206.10
Rate for Payer: BCBS MT POS	$217.55
Rate for Payer: BCBS MT Traditional	$229.00
Rate for Payer: Cash Price	$206.10
Rate for Payer: Cigna Commercial	$217.55
Rate for Payer: Cigna Medicare	$206.10
Rate for Payer: Medicaid All Medicaid	$210.68
Rate for Payer: Medicare All Medicare	$160.30
Rate for Payer: Monida Allegiance	$217.55
Rate for Payer: Monida First Choice Health	$222.13
Rate for Payer: Monida Montana Health Co-op	$217.55
Rate for Payer: Monida PacificSource	$217.55

SYNCH AUDIO-ONLY NEW MOD 45

Facility

$229.00

Service Code	CPT 98010
Hospital Charge Code	8098010
Hospital Revenue Code	521
Min. Negotiated Rate	$160.30
Max. Negotiated Rate	$229.00
Rate for Payer: Aetna Commercial	$217.55
Rate for Payer: Aetna Medicare	$206.10
Rate for Payer: BCBS MT CHIP	$206.10
Rate for Payer: BCBS MT Closed Plan Network	$217.55
Rate for Payer: BCBS MT HealthLink	$206.10
Rate for Payer: BCBS MT Medicare	$206.10
Rate for Payer: BCBS MT POS	$217.55
Rate for Payer: BCBS MT Traditional	$229.00
Rate for Payer: Cash Price	$206.10
Rate for Payer: Cigna Commercial	$217.55
Rate for Payer: Cigna Medicare	$206.10
Rate for Payer: Medicaid All Medicaid	$210.68
Rate for Payer: Medicare All Medicare	$160.30
Rate for Payer: Monida Allegiance	$217.55
Rate for Payer: Monida First Choice Health	$222.13
Rate for Payer: Monida Montana Health Co-op	$217.55
Rate for Payer: Monida PacificSource	$217.55

SYNCH AUDIO-ONLY NEW SF 15

Facility

$84.00

Service Code	CPT 98008
Hospital Charge Code	8098008
Hospital Revenue Code	521
Min. Negotiated Rate	$58.80
Max. Negotiated Rate	$84.00
Rate for Payer: Aetna Commercial	$79.80
Rate for Payer: Aetna Medicare	$75.60
Rate for Payer: BCBS MT CHIP	$75.60
Rate for Payer: BCBS MT Closed Plan Network	$79.80
Rate for Payer: BCBS MT HealthLink	$75.60
Rate for Payer: BCBS MT Medicare	$75.60
Rate for Payer: BCBS MT POS	$79.80
Rate for Payer: BCBS MT Traditional	$84.00
Rate for Payer: Cash Price	$75.60
Rate for Payer: Cigna Commercial	$79.80
Rate for Payer: Cigna Medicare	$75.60
Rate for Payer: Medicaid All Medicaid	$77.28
Rate for Payer: Medicare All Medicare	$58.80
Rate for Payer: Monida Allegiance	$79.80
Rate for Payer: Monida First Choice Health	$81.48
Rate for Payer: Monida Montana Health Co-op	$79.80
Rate for Payer: Monida PacificSource	$79.80

SYNCH AUDIO-ONLY NEW SF 15

Facility

$84.00

Service Code	CPT 98008
Hospital Charge Code	8098008
Hospital Revenue Code	521
Min. Negotiated Rate	$58.80
Max. Negotiated Rate	$84.00
Rate for Payer: Aetna Commercial	$79.80
Rate for Payer: Aetna Medicare	$75.60
Rate for Payer: BCBS MT CHIP	$75.60
Rate for Payer: BCBS MT Closed Plan Network	$79.80
Rate for Payer: BCBS MT HealthLink	$75.60
Rate for Payer: BCBS MT Medicare	$75.60
Rate for Payer: BCBS MT POS	$79.80
Rate for Payer: BCBS MT Traditional	$84.00
Rate for Payer: Cash Price	$75.60
Rate for Payer: Cigna Commercial	$79.80
Rate for Payer: Cigna Medicare	$75.60
Rate for Payer: Medicaid All Medicaid	$77.28
Rate for Payer: Medicare All Medicare	$58.80
Rate for Payer: Monida Allegiance	$79.80
Rate for Payer: Monida First Choice Health	$81.48
Rate for Payer: Monida Montana Health Co-op	$79.80
Rate for Payer: Monida PacificSource	$79.80

SYNCH AUDIO-VIDEO EST HI 40

Facility

$245.00

Service Code	CPT 98007
Hospital Charge Code	8098007
Hospital Revenue Code	521
Min. Negotiated Rate	$171.50
Max. Negotiated Rate	$245.00
Rate for Payer: Aetna Commercial	$232.75
Rate for Payer: Aetna Medicare	$220.50
Rate for Payer: BCBS MT CHIP	$220.50
Rate for Payer: BCBS MT Closed Plan Network	$232.75
Rate for Payer: BCBS MT HealthLink	$220.50
Rate for Payer: BCBS MT Medicare	$220.50
Rate for Payer: BCBS MT POS	$232.75
Rate for Payer: BCBS MT Traditional	$245.00
Rate for Payer: Cash Price	$220.50
Rate for Payer: Cigna Commercial	$232.75
Rate for Payer: Cigna Medicare	$220.50
Rate for Payer: Medicaid All Medicaid	$225.40
Rate for Payer: Medicare All Medicare	$171.50
Rate for Payer: Monida Allegiance	$232.75
Rate for Payer: Monida First Choice Health	$237.65
Rate for Payer: Monida Montana Health Co-op	$232.75
Rate for Payer: Monida PacificSource	$232.75

SYNCH AUDIO-VIDEO EST HI 40

Facility

$245.00

Service Code	CPT 98007
Hospital Charge Code	8098007
Hospital Revenue Code	521
Min. Negotiated Rate	$171.50
Max. Negotiated Rate	$245.00
Rate for Payer: Aetna Commercial	$232.75
Rate for Payer: Aetna Medicare	$220.50
Rate for Payer: BCBS MT CHIP	$220.50
Rate for Payer: BCBS MT Closed Plan Network	$232.75
Rate for Payer: BCBS MT HealthLink	$220.50
Rate for Payer: BCBS MT Medicare	$220.50
Rate for Payer: BCBS MT POS	$232.75
Rate for Payer: BCBS MT Traditional	$245.00
Rate for Payer: Cash Price	$220.50
Rate for Payer: Cigna Commercial	$232.75
Rate for Payer: Cigna Medicare	$220.50
Rate for Payer: Medicaid All Medicaid	$225.40
Rate for Payer: Medicare All Medicare	$171.50
Rate for Payer: Monida Allegiance	$232.75
Rate for Payer: Monida First Choice Health	$237.65
Rate for Payer: Monida Montana Health Co-op	$232.75
Rate for Payer: Monida PacificSource	$232.75

SYNCH AUDIO-VIDEO EST LOW 20

Facility

$122.00

Service Code	CPT 98005
Hospital Charge Code	8098005
Hospital Revenue Code	521
Min. Negotiated Rate	$85.40
Max. Negotiated Rate	$122.00
Rate for Payer: Aetna Commercial	$115.90
Rate for Payer: Aetna Medicare	$109.80
Rate for Payer: BCBS MT CHIP	$109.80
Rate for Payer: BCBS MT Closed Plan Network	$115.90
Rate for Payer: BCBS MT HealthLink	$109.80
Rate for Payer: BCBS MT Medicare	$109.80
Rate for Payer: BCBS MT POS	$115.90
Rate for Payer: BCBS MT Traditional	$122.00
Rate for Payer: Cash Price	$109.80
Rate for Payer: Cigna Commercial	$115.90
Rate for Payer: Cigna Medicare	$109.80
Rate for Payer: Medicaid All Medicaid	$112.24
Rate for Payer: Medicare All Medicare	$85.40
Rate for Payer: Monida Allegiance	$115.90
Rate for Payer: Monida First Choice Health	$118.34
Rate for Payer: Monida Montana Health Co-op	$115.90
Rate for Payer: Monida PacificSource	$115.90

SYNCH AUDIO-VIDEO EST LOW 20

Facility

$122.00

Service Code	CPT 98005
Hospital Charge Code	8098005
Hospital Revenue Code	521
Min. Negotiated Rate	$85.40
Max. Negotiated Rate	$122.00
Rate for Payer: Aetna Commercial	$115.90
Rate for Payer: Aetna Medicare	$109.80
Rate for Payer: BCBS MT CHIP	$109.80
Rate for Payer: BCBS MT Closed Plan Network	$115.90
Rate for Payer: BCBS MT HealthLink	$109.80
Rate for Payer: BCBS MT Medicare	$109.80
Rate for Payer: BCBS MT POS	$115.90
Rate for Payer: BCBS MT Traditional	$122.00
Rate for Payer: Cash Price	$109.80
Rate for Payer: Cigna Commercial	$115.90
Rate for Payer: Cigna Medicare	$109.80
Rate for Payer: Medicaid All Medicaid	$112.24
Rate for Payer: Medicare All Medicare	$85.40
Rate for Payer: Monida Allegiance	$115.90
Rate for Payer: Monida First Choice Health	$118.34
Rate for Payer: Monida Montana Health Co-op	$115.90
Rate for Payer: Monida PacificSource	$115.90

SYNCH AUDIO-VIDEO EST MOD 30

Facility

$182.00

Service Code	CPT 98006
Hospital Charge Code	8098006
Hospital Revenue Code	521
Min. Negotiated Rate	$127.40
Max. Negotiated Rate	$182.00
Rate for Payer: Aetna Commercial	$172.90
Rate for Payer: Aetna Medicare	$163.80
Rate for Payer: BCBS MT CHIP	$163.80
Rate for Payer: BCBS MT Closed Plan Network	$172.90
Rate for Payer: BCBS MT HealthLink	$163.80
Rate for Payer: BCBS MT Medicare	$163.80
Rate for Payer: BCBS MT POS	$172.90
Rate for Payer: BCBS MT Traditional	$182.00
Rate for Payer: Cash Price	$163.80
Rate for Payer: Cigna Commercial	$172.90
Rate for Payer: Cigna Medicare	$163.80
Rate for Payer: Medicaid All Medicaid	$167.44
Rate for Payer: Medicare All Medicare	$127.40
Rate for Payer: Monida Allegiance	$172.90
Rate for Payer: Monida First Choice Health	$176.54
Rate for Payer: Monida Montana Health Co-op	$172.90
Rate for Payer: Monida PacificSource	$172.90

SYNCH AUDIO-VIDEO EST MOD 30

Facility

$182.00

Service Code	CPT 98006
Hospital Charge Code	8098006
Hospital Revenue Code	521
Min. Negotiated Rate	$127.40
Max. Negotiated Rate	$182.00
Rate for Payer: Aetna Commercial	$172.90
Rate for Payer: Aetna Medicare	$163.80
Rate for Payer: BCBS MT CHIP	$163.80
Rate for Payer: BCBS MT Closed Plan Network	$172.90
Rate for Payer: BCBS MT HealthLink	$163.80
Rate for Payer: BCBS MT Medicare	$163.80
Rate for Payer: BCBS MT POS	$172.90
Rate for Payer: BCBS MT Traditional	$182.00
Rate for Payer: Cash Price	$163.80
Rate for Payer: Cigna Commercial	$172.90
Rate for Payer: Cigna Medicare	$163.80
Rate for Payer: Medicaid All Medicaid	$167.44
Rate for Payer: Medicare All Medicare	$127.40
Rate for Payer: Monida Allegiance	$172.90
Rate for Payer: Monida First Choice Health	$176.54
Rate for Payer: Monida Montana Health Co-op	$172.90
Rate for Payer: Monida PacificSource	$172.90

SYNCH AUDIO-VIDEO EST SF 10

Facility

$66.00

Service Code	CPT 98004
Hospital Charge Code	8098004
Hospital Revenue Code	521
Min. Negotiated Rate	$46.20
Max. Negotiated Rate	$66.00
Rate for Payer: Aetna Commercial	$62.70
Rate for Payer: Aetna Medicare	$59.40
Rate for Payer: BCBS MT CHIP	$59.40
Rate for Payer: BCBS MT Closed Plan Network	$62.70
Rate for Payer: BCBS MT HealthLink	$59.40
Rate for Payer: BCBS MT Medicare	$59.40
Rate for Payer: BCBS MT POS	$62.70
Rate for Payer: BCBS MT Traditional	$66.00
Rate for Payer: Cash Price	$59.40
Rate for Payer: Cigna Commercial	$62.70
Rate for Payer: Cigna Medicare	$59.40
Rate for Payer: Medicaid All Medicaid	$60.72
Rate for Payer: Medicare All Medicare	$46.20
Rate for Payer: Monida Allegiance	$62.70
Rate for Payer: Monida First Choice Health	$64.02
Rate for Payer: Monida Montana Health Co-op	$62.70
Rate for Payer: Monida PacificSource	$62.70

SYNCH AUDIO-VIDEO EST SF 10

Facility

$66.00

Service Code	CPT 98004
Hospital Charge Code	8098004
Hospital Revenue Code	521
Min. Negotiated Rate	$46.20
Max. Negotiated Rate	$66.00
Rate for Payer: Aetna Commercial	$62.70
Rate for Payer: Aetna Medicare	$59.40
Rate for Payer: BCBS MT CHIP	$59.40
Rate for Payer: BCBS MT Closed Plan Network	$62.70
Rate for Payer: BCBS MT HealthLink	$59.40
Rate for Payer: BCBS MT Medicare	$59.40
Rate for Payer: BCBS MT POS	$62.70
Rate for Payer: BCBS MT Traditional	$66.00
Rate for Payer: Cash Price	$59.40
Rate for Payer: Cigna Commercial	$62.70
Rate for Payer: Cigna Medicare	$59.40
Rate for Payer: Medicaid All Medicaid	$60.72
Rate for Payer: Medicare All Medicare	$46.20
Rate for Payer: Monida Allegiance	$62.70
Rate for Payer: Monida First Choice Health	$64.02
Rate for Payer: Monida Montana Health Co-op	$62.70
Rate for Payer: Monida PacificSource	$62.70

SYNCH AUDIO-VIDEO NEW HI 60

Facility

$329.00

Service Code	CPT 98003
Hospital Charge Code	8098003
Hospital Revenue Code	521
Min. Negotiated Rate	$230.30
Max. Negotiated Rate	$329.00
Rate for Payer: Aetna Commercial	$312.55
Rate for Payer: Aetna Medicare	$296.10
Rate for Payer: BCBS MT CHIP	$296.10
Rate for Payer: BCBS MT Closed Plan Network	$312.55
Rate for Payer: BCBS MT HealthLink	$296.10
Rate for Payer: BCBS MT Medicare	$296.10
Rate for Payer: BCBS MT POS	$312.55
Rate for Payer: BCBS MT Traditional	$329.00
Rate for Payer: Cash Price	$296.10
Rate for Payer: Cigna Commercial	$312.55
Rate for Payer: Cigna Medicare	$296.10
Rate for Payer: Medicaid All Medicaid	$302.68
Rate for Payer: Medicare All Medicare	$230.30
Rate for Payer: Monida Allegiance	$312.55
Rate for Payer: Monida First Choice Health	$319.13
Rate for Payer: Monida Montana Health Co-op	$312.55
Rate for Payer: Monida PacificSource	$312.55

SYNCH AUDIO-VIDEO NEW HI 60

Facility

$329.00

Service Code	CPT 98003
Hospital Charge Code	8098003
Hospital Revenue Code	521
Min. Negotiated Rate	$230.30
Max. Negotiated Rate	$329.00
Rate for Payer: Aetna Commercial	$312.55
Rate for Payer: Aetna Medicare	$296.10
Rate for Payer: BCBS MT CHIP	$296.10
Rate for Payer: BCBS MT Closed Plan Network	$312.55
Rate for Payer: BCBS MT HealthLink	$296.10
Rate for Payer: BCBS MT Medicare	$296.10
Rate for Payer: BCBS MT POS	$312.55
Rate for Payer: BCBS MT Traditional	$329.00
Rate for Payer: Cash Price	$296.10
Rate for Payer: Cigna Commercial	$312.55
Rate for Payer: Cigna Medicare	$296.10
Rate for Payer: Medicaid All Medicaid	$302.68
Rate for Payer: Medicare All Medicare	$230.30
Rate for Payer: Monida Allegiance	$312.55
Rate for Payer: Monida First Choice Health	$319.13
Rate for Payer: Monida Montana Health Co-op	$312.55
Rate for Payer: Monida PacificSource	$312.55

SYNCH AUDIO-VIDEO NEW LOW 30

Facility

$151.00

Service Code	CPT 98001
Hospital Charge Code	8098001
Hospital Revenue Code	521
Min. Negotiated Rate	$105.70
Max. Negotiated Rate	$151.00
Rate for Payer: Aetna Commercial	$143.45
Rate for Payer: Aetna Medicare	$135.90
Rate for Payer: BCBS MT CHIP	$135.90
Rate for Payer: BCBS MT Closed Plan Network	$143.45
Rate for Payer: BCBS MT HealthLink	$135.90
Rate for Payer: BCBS MT Medicare	$135.90
Rate for Payer: BCBS MT POS	$143.45
Rate for Payer: BCBS MT Traditional	$151.00
Rate for Payer: Cash Price	$135.90
Rate for Payer: Cigna Commercial	$143.45
Rate for Payer: Cigna Medicare	$135.90
Rate for Payer: Medicaid All Medicaid	$138.92
Rate for Payer: Medicare All Medicare	$105.70
Rate for Payer: Monida Allegiance	$143.45
Rate for Payer: Monida First Choice Health	$146.47
Rate for Payer: Monida Montana Health Co-op	$143.45
Rate for Payer: Monida PacificSource	$143.45

SYNCH AUDIO-VIDEO NEW LOW 30

Facility

$151.00

Service Code	CPT 98001
Hospital Charge Code	8098001
Hospital Revenue Code	521
Min. Negotiated Rate	$105.70
Max. Negotiated Rate	$151.00
Rate for Payer: Aetna Commercial	$143.45
Rate for Payer: Aetna Medicare	$135.90
Rate for Payer: BCBS MT CHIP	$135.90
Rate for Payer: BCBS MT Closed Plan Network	$143.45
Rate for Payer: BCBS MT HealthLink	$135.90
Rate for Payer: BCBS MT Medicare	$135.90
Rate for Payer: BCBS MT POS	$143.45
Rate for Payer: BCBS MT Traditional	$151.00
Rate for Payer: Cash Price	$135.90
Rate for Payer: Cigna Commercial	$143.45
Rate for Payer: Cigna Medicare	$135.90
Rate for Payer: Medicaid All Medicaid	$138.92
Rate for Payer: Medicare All Medicare	$105.70
Rate for Payer: Monida Allegiance	$143.45
Rate for Payer: Monida First Choice Health	$146.47
Rate for Payer: Monida Montana Health Co-op	$143.45
Rate for Payer: Monida PacificSource	$143.45

SYNCH AUDIO-VIDEO NEW MOD 45

Facility

$245.00

Service Code	CPT 98002
Hospital Charge Code	8098002
Hospital Revenue Code	521
Min. Negotiated Rate	$171.50
Max. Negotiated Rate	$245.00
Rate for Payer: Aetna Commercial	$232.75
Rate for Payer: Aetna Medicare	$220.50
Rate for Payer: BCBS MT CHIP	$220.50
Rate for Payer: BCBS MT Closed Plan Network	$232.75
Rate for Payer: BCBS MT HealthLink	$220.50
Rate for Payer: BCBS MT Medicare	$220.50
Rate for Payer: BCBS MT POS	$232.75
Rate for Payer: BCBS MT Traditional	$245.00
Rate for Payer: Cash Price	$220.50
Rate for Payer: Cigna Commercial	$232.75
Rate for Payer: Cigna Medicare	$220.50
Rate for Payer: Medicaid All Medicaid	$225.40
Rate for Payer: Medicare All Medicare	$171.50
Rate for Payer: Monida Allegiance	$232.75
Rate for Payer: Monida First Choice Health	$237.65
Rate for Payer: Monida Montana Health Co-op	$232.75
Rate for Payer: Monida PacificSource	$232.75

SYNCH AUDIO-VIDEO NEW MOD 45

Facility

$245.00

Service Code	CPT 98002
Hospital Charge Code	8098002
Hospital Revenue Code	521
Min. Negotiated Rate	$171.50
Max. Negotiated Rate	$245.00
Rate for Payer: Aetna Commercial	$232.75
Rate for Payer: Aetna Medicare	$220.50
Rate for Payer: BCBS MT CHIP	$220.50
Rate for Payer: BCBS MT Closed Plan Network	$232.75
Rate for Payer: BCBS MT HealthLink	$220.50
Rate for Payer: BCBS MT Medicare	$220.50
Rate for Payer: BCBS MT POS	$232.75
Rate for Payer: BCBS MT Traditional	$245.00
Rate for Payer: Cash Price	$220.50
Rate for Payer: Cigna Commercial	$232.75
Rate for Payer: Cigna Medicare	$220.50
Rate for Payer: Medicaid All Medicaid	$225.40
Rate for Payer: Medicare All Medicare	$171.50
Rate for Payer: Monida Allegiance	$232.75
Rate for Payer: Monida First Choice Health	$237.65
Rate for Payer: Monida Montana Health Co-op	$232.75
Rate for Payer: Monida PacificSource	$232.75

SYNCH AUDIO-VIDEO NEW SF 15

Facility

$88.00

Service Code	CPT 98000
Hospital Charge Code	8098000
Hospital Revenue Code	521
Min. Negotiated Rate	$61.60
Max. Negotiated Rate	$88.00
Rate for Payer: Aetna Commercial	$83.60
Rate for Payer: Aetna Medicare	$79.20
Rate for Payer: BCBS MT CHIP	$79.20
Rate for Payer: BCBS MT Closed Plan Network	$83.60
Rate for Payer: BCBS MT HealthLink	$79.20
Rate for Payer: BCBS MT Medicare	$79.20
Rate for Payer: BCBS MT POS	$83.60
Rate for Payer: BCBS MT Traditional	$88.00
Rate for Payer: Cash Price	$79.20
Rate for Payer: Cigna Commercial	$83.60
Rate for Payer: Cigna Medicare	$79.20
Rate for Payer: Medicaid All Medicaid	$80.96
Rate for Payer: Medicare All Medicare	$61.60
Rate for Payer: Monida Allegiance	$83.60
Rate for Payer: Monida First Choice Health	$85.36
Rate for Payer: Monida Montana Health Co-op	$83.60
Rate for Payer: Monida PacificSource	$83.60

SYNCH AUDIO-VIDEO NEW SF 15

Facility

$88.00

Service Code	CPT 98000
Hospital Charge Code	8098000
Hospital Revenue Code	521
Min. Negotiated Rate	$61.60
Max. Negotiated Rate	$88.00
Rate for Payer: Aetna Commercial	$83.60
Rate for Payer: Aetna Medicare	$79.20
Rate for Payer: BCBS MT CHIP	$79.20
Rate for Payer: BCBS MT Closed Plan Network	$83.60
Rate for Payer: BCBS MT HealthLink	$79.20
Rate for Payer: BCBS MT Medicare	$79.20
Rate for Payer: BCBS MT POS	$83.60
Rate for Payer: BCBS MT Traditional	$88.00
Rate for Payer: Cash Price	$79.20
Rate for Payer: Cigna Commercial	$83.60
Rate for Payer: Cigna Medicare	$79.20
Rate for Payer: Medicaid All Medicaid	$80.96
Rate for Payer: Medicare All Medicare	$61.60
Rate for Payer: Monida Allegiance	$83.60
Rate for Payer: Monida First Choice Health	$85.36
Rate for Payer: Monida Montana Health Co-op	$83.60
Rate for Payer: Monida PacificSource	$83.60

SYPHILLIS SCREEN W REFLEX

Facility

$95.00

Service Code	CPT 86780
Hospital Charge Code	4087989
Hospital Revenue Code	302
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

SYPHILLIS SCREEN W REFLEX

Facility

$95.00

Service Code	CPT 86780
Hospital Charge Code	4087989
Hospital Revenue Code	302
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

Know your out-of-pocket cost for care.

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