Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

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

ST OFC/OUT-PT (MINOR 5MIN)

Facility

$94.00

Service Code	CPT 99211
Hospital Charge Code	6399211
Hospital Revenue Code	440
Min. Negotiated Rate	$65.80
Max. Negotiated Rate	$94.00
Rate for Payer: Aetna Commercial	$89.30
Rate for Payer: Aetna Medicare	$84.60
Rate for Payer: BCBS MT CHIP	$84.60
Rate for Payer: BCBS MT Closed Plan Network	$89.30
Rate for Payer: BCBS MT HealthLink	$84.60
Rate for Payer: BCBS MT Medicare	$84.60
Rate for Payer: BCBS MT POS	$89.30
Rate for Payer: BCBS MT Traditional	$94.00
Rate for Payer: Cash Price	$84.60
Rate for Payer: Cigna Commercial	$89.30
Rate for Payer: Cigna Medicare	$84.60
Rate for Payer: Medicaid All Medicaid	$86.48
Rate for Payer: Medicare All Medicare	$65.80
Rate for Payer: Monida Allegiance	$89.30
Rate for Payer: Monida First Choice Health	$91.18
Rate for Payer: Monida Montana Health Co-op	$89.30
Rate for Payer: Monida PacificSource	$89.30

ST OFC/OUT-PT (MINOR 5MIN)

Facility

$94.00

Service Code	CPT 99211
Hospital Charge Code	6399211
Hospital Revenue Code	440
Min. Negotiated Rate	$65.80
Max. Negotiated Rate	$94.00
Rate for Payer: Aetna Commercial	$89.30
Rate for Payer: Aetna Medicare	$84.60
Rate for Payer: BCBS MT CHIP	$84.60
Rate for Payer: BCBS MT Closed Plan Network	$89.30
Rate for Payer: BCBS MT HealthLink	$84.60
Rate for Payer: BCBS MT Medicare	$84.60
Rate for Payer: BCBS MT POS	$89.30
Rate for Payer: BCBS MT Traditional	$94.00
Rate for Payer: Cash Price	$84.60
Rate for Payer: Cigna Commercial	$89.30
Rate for Payer: Cigna Medicare	$84.60
Rate for Payer: Medicaid All Medicaid	$86.48
Rate for Payer: Medicare All Medicare	$65.80
Rate for Payer: Monida Allegiance	$89.30
Rate for Payer: Monida First Choice Health	$91.18
Rate for Payer: Monida Montana Health Co-op	$89.30
Rate for Payer: Monida PacificSource	$89.30

ST OFC/OUT-PT OF EST PT(2/3 COMP 10MIN)

Facility

$179.00

Service Code	CPT 99212
Hospital Charge Code	6399212
Hospital Revenue Code	440
Min. Negotiated Rate	$125.30
Max. Negotiated Rate	$179.00
Rate for Payer: Aetna Commercial	$170.05
Rate for Payer: Aetna Medicare	$161.10
Rate for Payer: BCBS MT CHIP	$161.10
Rate for Payer: BCBS MT Closed Plan Network	$170.05
Rate for Payer: BCBS MT HealthLink	$161.10
Rate for Payer: BCBS MT Medicare	$161.10
Rate for Payer: BCBS MT POS	$170.05
Rate for Payer: BCBS MT Traditional	$179.00
Rate for Payer: Cash Price	$161.10
Rate for Payer: Cigna Commercial	$170.05
Rate for Payer: Cigna Medicare	$161.10
Rate for Payer: Medicaid All Medicaid	$164.68
Rate for Payer: Medicare All Medicare	$125.30
Rate for Payer: Monida Allegiance	$170.05
Rate for Payer: Monida First Choice Health	$173.63
Rate for Payer: Monida Montana Health Co-op	$170.05
Rate for Payer: Monida PacificSource	$170.05

ST OFC/OUT-PT OF EST PT(2/3 COMP 10MIN)

Facility

$179.00

Service Code	CPT 99212
Hospital Charge Code	6399212
Hospital Revenue Code	440
Min. Negotiated Rate	$125.30
Max. Negotiated Rate	$179.00
Rate for Payer: Aetna Commercial	$170.05
Rate for Payer: Aetna Medicare	$161.10
Rate for Payer: BCBS MT CHIP	$161.10
Rate for Payer: BCBS MT Closed Plan Network	$170.05
Rate for Payer: BCBS MT HealthLink	$161.10
Rate for Payer: BCBS MT Medicare	$161.10
Rate for Payer: BCBS MT POS	$170.05
Rate for Payer: BCBS MT Traditional	$179.00
Rate for Payer: Cash Price	$161.10
Rate for Payer: Cigna Commercial	$170.05
Rate for Payer: Cigna Medicare	$161.10
Rate for Payer: Medicaid All Medicaid	$164.68
Rate for Payer: Medicare All Medicare	$125.30
Rate for Payer: Monida Allegiance	$170.05
Rate for Payer: Monida First Choice Health	$173.63
Rate for Payer: Monida Montana Health Co-op	$170.05
Rate for Payer: Monida PacificSource	$170.05

ST OFC/OUT-PT OF NEW PT

Facility

$105.00

Service Code	CPT 99201
Hospital Charge Code	6399201
Hospital Revenue Code	440
Min. Negotiated Rate	$73.50
Max. Negotiated Rate	$105.00
Rate for Payer: Aetna Commercial	$99.75
Rate for Payer: Aetna Medicare	$94.50
Rate for Payer: BCBS MT CHIP	$94.50
Rate for Payer: BCBS MT Closed Plan Network	$99.75
Rate for Payer: BCBS MT HealthLink	$94.50
Rate for Payer: BCBS MT Medicare	$94.50
Rate for Payer: BCBS MT POS	$99.75
Rate for Payer: BCBS MT Traditional	$105.00
Rate for Payer: Cash Price	$94.50
Rate for Payer: Cigna Commercial	$99.75
Rate for Payer: Cigna Medicare	$94.50
Rate for Payer: Medicaid All Medicaid	$96.60
Rate for Payer: Medicare All Medicare	$73.50
Rate for Payer: Monida Allegiance	$99.75
Rate for Payer: Monida First Choice Health	$101.85
Rate for Payer: Monida Montana Health Co-op	$99.75
Rate for Payer: Monida PacificSource	$99.75

ST OFC/OUT-PT OF NEW PT

Facility

$105.00

Service Code	CPT 99201
Hospital Charge Code	6399201
Hospital Revenue Code	440
Min. Negotiated Rate	$73.50
Max. Negotiated Rate	$105.00
Rate for Payer: Aetna Commercial	$99.75
Rate for Payer: Aetna Medicare	$94.50
Rate for Payer: BCBS MT CHIP	$94.50
Rate for Payer: BCBS MT Closed Plan Network	$99.75
Rate for Payer: BCBS MT HealthLink	$94.50
Rate for Payer: BCBS MT Medicare	$94.50
Rate for Payer: BCBS MT POS	$99.75
Rate for Payer: BCBS MT Traditional	$105.00
Rate for Payer: Cash Price	$94.50
Rate for Payer: Cigna Commercial	$99.75
Rate for Payer: Cigna Medicare	$94.50
Rate for Payer: Medicaid All Medicaid	$96.60
Rate for Payer: Medicare All Medicare	$73.50
Rate for Payer: Monida Allegiance	$99.75
Rate for Payer: Monida First Choice Health	$101.85
Rate for Payer: Monida Montana Health Co-op	$99.75
Rate for Payer: Monida PacificSource	$99.75

.STOOL CULTURE, ADDITIONAL PATHOGENS

Facility

$71.00

Service Code	CPT 87046
Hospital Charge Code	4087046
Hospital Revenue Code	300
Min. Negotiated Rate	$49.70
Max. Negotiated Rate	$71.00
Rate for Payer: Aetna Commercial	$67.45
Rate for Payer: Aetna Medicare	$63.90
Rate for Payer: BCBS MT CHIP	$63.90
Rate for Payer: BCBS MT Closed Plan Network	$67.45
Rate for Payer: BCBS MT HealthLink	$63.90
Rate for Payer: BCBS MT Medicare	$63.90
Rate for Payer: BCBS MT POS	$67.45
Rate for Payer: BCBS MT Traditional	$71.00
Rate for Payer: Cash Price	$63.90
Rate for Payer: Cigna Commercial	$67.45
Rate for Payer: Cigna Medicare	$63.90
Rate for Payer: Medicaid All Medicaid	$65.32
Rate for Payer: Medicare All Medicare	$49.70
Rate for Payer: Monida Allegiance	$67.45
Rate for Payer: Monida First Choice Health	$68.87
Rate for Payer: Monida Montana Health Co-op	$67.45
Rate for Payer: Monida PacificSource	$67.45

.STOOL CULTURE, ADDITIONAL PATHOGENS

Facility

$71.00

Service Code	CPT 87046
Hospital Charge Code	4087046
Hospital Revenue Code	300
Min. Negotiated Rate	$49.70
Max. Negotiated Rate	$71.00
Rate for Payer: Aetna Commercial	$67.45
Rate for Payer: Aetna Medicare	$63.90
Rate for Payer: BCBS MT CHIP	$63.90
Rate for Payer: BCBS MT Closed Plan Network	$67.45
Rate for Payer: BCBS MT HealthLink	$63.90
Rate for Payer: BCBS MT Medicare	$63.90
Rate for Payer: BCBS MT POS	$67.45
Rate for Payer: BCBS MT Traditional	$71.00
Rate for Payer: Cash Price	$63.90
Rate for Payer: Cigna Commercial	$67.45
Rate for Payer: Cigna Medicare	$63.90
Rate for Payer: Medicaid All Medicaid	$65.32
Rate for Payer: Medicare All Medicare	$49.70
Rate for Payer: Monida Allegiance	$67.45
Rate for Payer: Monida First Choice Health	$68.87
Rate for Payer: Monida Montana Health Co-op	$67.45
Rate for Payer: Monida PacificSource	$67.45

.STOOL CULTURE AEROBIC, SALM/SHIG

Facility

$71.00

Service Code	CPT 87045
Hospital Charge Code	4087045
Hospital Revenue Code	300
Min. Negotiated Rate	$49.70
Max. Negotiated Rate	$71.00
Rate for Payer: Aetna Commercial	$67.45
Rate for Payer: Aetna Medicare	$63.90
Rate for Payer: BCBS MT CHIP	$63.90
Rate for Payer: BCBS MT Closed Plan Network	$67.45
Rate for Payer: BCBS MT HealthLink	$63.90
Rate for Payer: BCBS MT Medicare	$63.90
Rate for Payer: BCBS MT POS	$67.45
Rate for Payer: BCBS MT Traditional	$71.00
Rate for Payer: Cash Price	$63.90
Rate for Payer: Cigna Commercial	$67.45
Rate for Payer: Cigna Medicare	$63.90
Rate for Payer: Medicaid All Medicaid	$65.32
Rate for Payer: Medicare All Medicare	$49.70
Rate for Payer: Monida Allegiance	$67.45
Rate for Payer: Monida First Choice Health	$68.87
Rate for Payer: Monida Montana Health Co-op	$67.45
Rate for Payer: Monida PacificSource	$67.45

.STOOL CULTURE AEROBIC, SALM/SHIG

Facility

$71.00

Service Code	CPT 87045
Hospital Charge Code	4087045
Hospital Revenue Code	300
Min. Negotiated Rate	$49.70
Max. Negotiated Rate	$71.00
Rate for Payer: Aetna Commercial	$67.45
Rate for Payer: Aetna Medicare	$63.90
Rate for Payer: BCBS MT CHIP	$63.90
Rate for Payer: BCBS MT Closed Plan Network	$67.45
Rate for Payer: BCBS MT HealthLink	$63.90
Rate for Payer: BCBS MT Medicare	$63.90
Rate for Payer: BCBS MT POS	$67.45
Rate for Payer: BCBS MT Traditional	$71.00
Rate for Payer: Cash Price	$63.90
Rate for Payer: Cigna Commercial	$67.45
Rate for Payer: Cigna Medicare	$63.90
Rate for Payer: Medicaid All Medicaid	$65.32
Rate for Payer: Medicare All Medicare	$49.70
Rate for Payer: Monida Allegiance	$67.45
Rate for Payer: Monida First Choice Health	$68.87
Rate for Payer: Monida Montana Health Co-op	$67.45
Rate for Payer: Monida PacificSource	$67.45

STOOL WBC

Facility

$65.00

Service Code	CPT 89055
Hospital Charge Code	4088070
Hospital Revenue Code	302
Min. Negotiated Rate	$45.50
Max. Negotiated Rate	$65.00
Rate for Payer: Aetna Commercial	$61.75
Rate for Payer: Aetna Medicare	$58.50
Rate for Payer: BCBS MT CHIP	$58.50
Rate for Payer: BCBS MT Closed Plan Network	$61.75
Rate for Payer: BCBS MT HealthLink	$58.50
Rate for Payer: BCBS MT Medicare	$58.50
Rate for Payer: BCBS MT POS	$61.75
Rate for Payer: BCBS MT Traditional	$65.00
Rate for Payer: Cash Price	$58.50
Rate for Payer: Cigna Commercial	$61.75
Rate for Payer: Cigna Medicare	$58.50
Rate for Payer: Medicaid All Medicaid	$59.80
Rate for Payer: Medicare All Medicare	$45.50
Rate for Payer: Monida Allegiance	$61.75
Rate for Payer: Monida First Choice Health	$63.05
Rate for Payer: Monida Montana Health Co-op	$61.75
Rate for Payer: Monida PacificSource	$61.75

STOOL WBC

Facility

$65.00

Service Code	CPT 89055
Hospital Charge Code	4088070
Hospital Revenue Code	302
Min. Negotiated Rate	$45.50
Max. Negotiated Rate	$65.00
Rate for Payer: Aetna Commercial	$61.75
Rate for Payer: Aetna Medicare	$58.50
Rate for Payer: BCBS MT CHIP	$58.50
Rate for Payer: BCBS MT Closed Plan Network	$61.75
Rate for Payer: BCBS MT HealthLink	$58.50
Rate for Payer: BCBS MT Medicare	$58.50
Rate for Payer: BCBS MT POS	$61.75
Rate for Payer: BCBS MT Traditional	$65.00
Rate for Payer: Cash Price	$58.50
Rate for Payer: Cigna Commercial	$61.75
Rate for Payer: Cigna Medicare	$58.50
Rate for Payer: Medicaid All Medicaid	$59.80
Rate for Payer: Medicare All Medicare	$45.50
Rate for Payer: Monida Allegiance	$61.75
Rate for Payer: Monida First Choice Health	$63.05
Rate for Payer: Monida Montana Health Co-op	$61.75
Rate for Payer: Monida PacificSource	$61.75

STRAPPNG OF THE KNEE

Facility

$220.00

Service Code	CPT 29530
Hospital Charge Code	8029530
Hospital Revenue Code	521
Min. Negotiated Rate	$154.00
Max. Negotiated Rate	$220.00
Rate for Payer: Aetna Commercial	$209.00
Rate for Payer: Aetna Medicare	$198.00
Rate for Payer: BCBS MT CHIP	$198.00
Rate for Payer: BCBS MT Closed Plan Network	$209.00
Rate for Payer: BCBS MT HealthLink	$198.00
Rate for Payer: BCBS MT Medicare	$198.00
Rate for Payer: BCBS MT POS	$209.00
Rate for Payer: BCBS MT Traditional	$220.00
Rate for Payer: Cash Price	$198.00
Rate for Payer: Cigna Commercial	$209.00
Rate for Payer: Cigna Medicare	$198.00
Rate for Payer: Medicaid All Medicaid	$202.40
Rate for Payer: Medicare All Medicare	$154.00
Rate for Payer: Monida Allegiance	$209.00
Rate for Payer: Monida First Choice Health	$213.40
Rate for Payer: Monida Montana Health Co-op	$209.00
Rate for Payer: Monida PacificSource	$209.00

Know your out-of-pocket cost for care.

All Charges