Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

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

STREP ABBOTT

Facility

$90.00

Service Code	CPT 87880
Hospital Charge Code	4087919
Hospital Revenue Code	300
Min. Negotiated Rate	$63.00
Max. Negotiated Rate	$90.00
Rate for Payer: Aetna Commercial	$85.50
Rate for Payer: Aetna Medicare	$81.00
Rate for Payer: BCBS MT CHIP	$81.00
Rate for Payer: BCBS MT Closed Plan Network	$85.50
Rate for Payer: BCBS MT HealthLink	$81.00
Rate for Payer: BCBS MT Medicare	$81.00
Rate for Payer: BCBS MT POS	$85.50
Rate for Payer: BCBS MT Traditional	$90.00
Rate for Payer: Cash Price	$81.00
Rate for Payer: Cigna Commercial	$85.50
Rate for Payer: Cigna Medicare	$81.00
Rate for Payer: Medicaid All Medicaid	$82.80
Rate for Payer: Medicare All Medicare	$63.00
Rate for Payer: Monida Allegiance	$85.50
Rate for Payer: Monida First Choice Health	$87.30
Rate for Payer: Monida Montana Health Co-op	$85.50
Rate for Payer: Monida PacificSource	$85.50

STREP ABBOTT

Facility

$90.00

Service Code	CPT 87880
Hospital Charge Code	4087919
Hospital Revenue Code	300
Min. Negotiated Rate	$63.00
Max. Negotiated Rate	$90.00
Rate for Payer: Aetna Commercial	$85.50
Rate for Payer: Aetna Medicare	$81.00
Rate for Payer: BCBS MT CHIP	$81.00
Rate for Payer: BCBS MT Closed Plan Network	$85.50
Rate for Payer: BCBS MT HealthLink	$81.00
Rate for Payer: BCBS MT Medicare	$81.00
Rate for Payer: BCBS MT POS	$85.50
Rate for Payer: BCBS MT Traditional	$90.00
Rate for Payer: Cash Price	$81.00
Rate for Payer: Cigna Commercial	$85.50
Rate for Payer: Cigna Medicare	$81.00
Rate for Payer: Medicaid All Medicaid	$82.80
Rate for Payer: Medicare All Medicare	$63.00
Rate for Payer: Monida Allegiance	$85.50
Rate for Payer: Monida First Choice Health	$87.30
Rate for Payer: Monida Montana Health Co-op	$85.50
Rate for Payer: Monida PacificSource	$85.50

STREP PNEUMO AB IGG 23 SEROTYPES

Facility

$156.00

Service Code	CPT 86317
Hospital Charge Code	4088115
Hospital Revenue Code	302
Min. Negotiated Rate	$109.20
Max. Negotiated Rate	$156.00
Rate for Payer: Aetna Commercial	$148.20
Rate for Payer: Aetna Medicare	$140.40
Rate for Payer: BCBS MT CHIP	$140.40
Rate for Payer: BCBS MT Closed Plan Network	$148.20
Rate for Payer: BCBS MT HealthLink	$140.40
Rate for Payer: BCBS MT Medicare	$140.40
Rate for Payer: BCBS MT POS	$148.20
Rate for Payer: BCBS MT Traditional	$156.00
Rate for Payer: Cash Price	$140.40
Rate for Payer: Cigna Commercial	$148.20
Rate for Payer: Cigna Medicare	$140.40
Rate for Payer: Medicaid All Medicaid	$143.52
Rate for Payer: Medicare All Medicare	$109.20
Rate for Payer: Monida Allegiance	$148.20
Rate for Payer: Monida First Choice Health	$151.32
Rate for Payer: Monida Montana Health Co-op	$148.20
Rate for Payer: Monida PacificSource	$148.20

STREP PNEUMO AB IGG 23 SEROTYPES

Facility

$156.00

Service Code	CPT 86317
Hospital Charge Code	4088115
Hospital Revenue Code	302
Min. Negotiated Rate	$109.20
Max. Negotiated Rate	$156.00
Rate for Payer: Aetna Commercial	$148.20
Rate for Payer: Aetna Medicare	$140.40
Rate for Payer: BCBS MT CHIP	$140.40
Rate for Payer: BCBS MT Closed Plan Network	$148.20
Rate for Payer: BCBS MT HealthLink	$140.40
Rate for Payer: BCBS MT Medicare	$140.40
Rate for Payer: BCBS MT POS	$148.20
Rate for Payer: BCBS MT Traditional	$156.00
Rate for Payer: Cash Price	$140.40
Rate for Payer: Cigna Commercial	$148.20
Rate for Payer: Cigna Medicare	$140.40
Rate for Payer: Medicaid All Medicaid	$143.52
Rate for Payer: Medicare All Medicare	$109.20
Rate for Payer: Monida Allegiance	$148.20
Rate for Payer: Monida First Choice Health	$151.32
Rate for Payer: Monida Montana Health Co-op	$148.20
Rate for Payer: Monida PacificSource	$148.20

STREP PNEUMO URINE AG

Facility

$70.00

Service Code	CPT 87449
Hospital Charge Code	4088065
Hospital Revenue Code	302
Min. Negotiated Rate	$49.00
Max. Negotiated Rate	$70.00
Rate for Payer: Aetna Commercial	$66.50
Rate for Payer: Aetna Medicare	$63.00
Rate for Payer: BCBS MT CHIP	$63.00
Rate for Payer: BCBS MT Closed Plan Network	$66.50
Rate for Payer: BCBS MT HealthLink	$63.00
Rate for Payer: BCBS MT Medicare	$63.00
Rate for Payer: BCBS MT POS	$66.50
Rate for Payer: BCBS MT Traditional	$70.00
Rate for Payer: Cash Price	$63.00
Rate for Payer: Cigna Commercial	$66.50
Rate for Payer: Cigna Medicare	$63.00
Rate for Payer: Medicaid All Medicaid	$64.40
Rate for Payer: Medicare All Medicare	$49.00
Rate for Payer: Monida Allegiance	$66.50
Rate for Payer: Monida First Choice Health	$67.90
Rate for Payer: Monida Montana Health Co-op	$66.50
Rate for Payer: Monida PacificSource	$66.50

STREP PNEUMO URINE AG

Facility

$70.00

Service Code	CPT 87449
Hospital Charge Code	4088065
Hospital Revenue Code	302
Min. Negotiated Rate	$49.00
Max. Negotiated Rate	$70.00
Rate for Payer: Aetna Commercial	$66.50
Rate for Payer: Aetna Medicare	$63.00
Rate for Payer: BCBS MT CHIP	$63.00
Rate for Payer: BCBS MT Closed Plan Network	$66.50
Rate for Payer: BCBS MT HealthLink	$63.00
Rate for Payer: BCBS MT Medicare	$63.00
Rate for Payer: BCBS MT POS	$66.50
Rate for Payer: BCBS MT Traditional	$70.00
Rate for Payer: Cash Price	$63.00
Rate for Payer: Cigna Commercial	$66.50
Rate for Payer: Cigna Medicare	$63.00
Rate for Payer: Medicaid All Medicaid	$64.40
Rate for Payer: Medicare All Medicare	$49.00
Rate for Payer: Monida Allegiance	$66.50
Rate for Payer: Monida First Choice Health	$67.90
Rate for Payer: Monida Montana Health Co-op	$66.50
Rate for Payer: Monida PacificSource	$66.50

STRESS ECHO DOBUTAMINE

Professional

Both

$264.00

Service Code	CPT 93350
Hospital Charge Code	50002427
Hospital Revenue Code	972
Min. Negotiated Rate	$184.80
Max. Negotiated Rate	$256.08
Rate for Payer: Aetna Commercial	$250.80
Rate for Payer: Aetna Medicare	$237.60
Rate for Payer: Cash Price	$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

STRESS ECHO DOBUTAMINE ORDER/EXAM

Facility

$2,163.00

Service Code	CPT 93350
Hospital Charge Code	5193351
Hospital Revenue Code	482
Min. Negotiated Rate	$1,514.10
Max. Negotiated Rate	$2,163.00
Rate for Payer: Aetna Commercial	$2,054.85
Rate for Payer: Aetna Medicare	$1,946.70
Rate for Payer: BCBS MT CHIP	$1,946.70
Rate for Payer: BCBS MT Closed Plan Network	$2,054.85
Rate for Payer: BCBS MT HealthLink	$1,946.70
Rate for Payer: BCBS MT Medicare	$1,946.70
Rate for Payer: BCBS MT POS	$2,054.85
Rate for Payer: BCBS MT Traditional	$2,163.00
Rate for Payer: Cash Price	$1,946.70
Rate for Payer: Cigna Commercial	$2,054.85
Rate for Payer: Cigna Medicare	$1,946.70
Rate for Payer: Medicaid All Medicaid	$1,989.96
Rate for Payer: Medicare All Medicare	$1,514.10
Rate for Payer: Monida Allegiance	$2,054.85
Rate for Payer: Monida First Choice Health	$2,098.11
Rate for Payer: Monida Montana Health Co-op	$2,054.85
Rate for Payer: Monida PacificSource	$2,054.85

STRESS ECHO DOBUTAMINE ORDER/EXAM

Facility

$2,163.00

Service Code	CPT 93350
Hospital Charge Code	5193351
Hospital Revenue Code	482
Min. Negotiated Rate	$1,514.10
Max. Negotiated Rate	$2,163.00
Rate for Payer: Aetna Commercial	$2,054.85
Rate for Payer: Aetna Medicare	$1,946.70
Rate for Payer: BCBS MT CHIP	$1,946.70
Rate for Payer: BCBS MT Closed Plan Network	$2,054.85
Rate for Payer: BCBS MT HealthLink	$1,946.70
Rate for Payer: BCBS MT Medicare	$1,946.70
Rate for Payer: BCBS MT POS	$2,054.85
Rate for Payer: BCBS MT Traditional	$2,163.00
Rate for Payer: Cash Price	$1,946.70
Rate for Payer: Cigna Commercial	$2,054.85
Rate for Payer: Cigna Medicare	$1,946.70
Rate for Payer: Medicaid All Medicaid	$1,989.96
Rate for Payer: Medicare All Medicare	$1,514.10
Rate for Payer: Monida Allegiance	$2,054.85
Rate for Payer: Monida First Choice Health	$2,098.11
Rate for Payer: Monida Montana Health Co-op	$2,054.85
Rate for Payer: Monida PacificSource	$2,054.85

STRESS ECHO TREADMILL ORDER/EXAM

Facility

$2,163.00

Service Code	CPT 93350
Hospital Charge Code	5193350
Hospital Revenue Code	482
Min. Negotiated Rate	$1,514.10
Max. Negotiated Rate	$2,163.00
Rate for Payer: Aetna Commercial	$2,054.85
Rate for Payer: Aetna Medicare	$1,946.70
Rate for Payer: BCBS MT CHIP	$1,946.70
Rate for Payer: BCBS MT Closed Plan Network	$2,054.85
Rate for Payer: BCBS MT HealthLink	$1,946.70
Rate for Payer: BCBS MT Medicare	$1,946.70
Rate for Payer: BCBS MT POS	$2,054.85
Rate for Payer: BCBS MT Traditional	$2,163.00
Rate for Payer: Cash Price	$1,946.70
Rate for Payer: Cigna Commercial	$2,054.85
Rate for Payer: Cigna Medicare	$1,946.70
Rate for Payer: Medicaid All Medicaid	$1,989.96
Rate for Payer: Medicare All Medicare	$1,514.10
Rate for Payer: Monida Allegiance	$2,054.85
Rate for Payer: Monida First Choice Health	$2,098.11
Rate for Payer: Monida Montana Health Co-op	$2,054.85
Rate for Payer: Monida PacificSource	$2,054.85

STRESS ECHO TREADMILL ORDER/EXAM

Facility

$2,163.00

Service Code	CPT 93350
Hospital Charge Code	5193350
Hospital Revenue Code	482
Min. Negotiated Rate	$1,514.10
Max. Negotiated Rate	$2,163.00
Rate for Payer: Aetna Commercial	$2,054.85
Rate for Payer: Aetna Medicare	$1,946.70
Rate for Payer: BCBS MT CHIP	$1,946.70
Rate for Payer: BCBS MT Closed Plan Network	$2,054.85
Rate for Payer: BCBS MT HealthLink	$1,946.70
Rate for Payer: BCBS MT Medicare	$1,946.70
Rate for Payer: BCBS MT POS	$2,054.85
Rate for Payer: BCBS MT Traditional	$2,163.00
Rate for Payer: Cash Price	$1,946.70
Rate for Payer: Cigna Commercial	$2,054.85
Rate for Payer: Cigna Medicare	$1,946.70
Rate for Payer: Medicaid All Medicaid	$1,989.96
Rate for Payer: Medicare All Medicare	$1,514.10
Rate for Payer: Monida Allegiance	$2,054.85
Rate for Payer: Monida First Choice Health	$2,098.11
Rate for Payer: Monida Montana Health Co-op	$2,054.85
Rate for Payer: Monida PacificSource	$2,054.85

STRETCH BANDAGE 2''

Facility

$4.00

Hospital Charge Code	80030023
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

STRETCH BANDAGE 2''

Facility

$4.00

Hospital Charge Code	80030023
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

STRETCH BANDAGE 2'' STERILE

Facility

$11.00

Hospital Charge Code	80030026
Hospital Revenue Code	270
Min. Negotiated Rate	$7.70
Max. Negotiated Rate	$11.00
Rate for Payer: Aetna Commercial	$10.45
Rate for Payer: Aetna Medicare	$9.90
Rate for Payer: BCBS MT CHIP	$9.90
Rate for Payer: BCBS MT Closed Plan Network	$10.45
Rate for Payer: BCBS MT HealthLink	$9.90
Rate for Payer: BCBS MT Medicare	$9.90
Rate for Payer: BCBS MT POS	$10.45
Rate for Payer: BCBS MT Traditional	$11.00
Rate for Payer: Cash Price	$9.90
Rate for Payer: Cigna Commercial	$10.45
Rate for Payer: Cigna Medicare	$9.90
Rate for Payer: Medicaid All Medicaid	$10.12
Rate for Payer: Medicare All Medicare	$7.70
Rate for Payer: Monida Allegiance	$10.45
Rate for Payer: Monida First Choice Health	$10.67
Rate for Payer: Monida Montana Health Co-op	$10.45
Rate for Payer: Monida PacificSource	$10.45

STRETCH BANDAGE 2'' STERILE

Facility

$11.00

Hospital Charge Code	80030026
Hospital Revenue Code	270
Min. Negotiated Rate	$7.70
Max. Negotiated Rate	$11.00
Rate for Payer: Aetna Commercial	$10.45
Rate for Payer: Aetna Medicare	$9.90
Rate for Payer: BCBS MT CHIP	$9.90
Rate for Payer: BCBS MT Closed Plan Network	$10.45
Rate for Payer: BCBS MT HealthLink	$9.90
Rate for Payer: BCBS MT Medicare	$9.90
Rate for Payer: BCBS MT POS	$10.45
Rate for Payer: BCBS MT Traditional	$11.00
Rate for Payer: Cash Price	$9.90
Rate for Payer: Cigna Commercial	$10.45
Rate for Payer: Cigna Medicare	$9.90
Rate for Payer: Medicaid All Medicaid	$10.12
Rate for Payer: Medicare All Medicare	$7.70
Rate for Payer: Monida Allegiance	$10.45
Rate for Payer: Monida First Choice Health	$10.67
Rate for Payer: Monida Montana Health Co-op	$10.45
Rate for Payer: Monida PacificSource	$10.45

STRETCH BANDAGE 3''

Facility

$4.00

Hospital Charge Code	80030024
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

STRETCH BANDAGE 3''

Facility

$4.00

Hospital Charge Code	80030024
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

STRETCH BANDAGE 3'' STERILE

Facility

$13.00

Hospital Charge Code	80030027
Hospital Revenue Code	270
Min. Negotiated Rate	$9.10
Max. Negotiated Rate	$13.00
Rate for Payer: Aetna Commercial	$12.35
Rate for Payer: Aetna Medicare	$11.70
Rate for Payer: BCBS MT CHIP	$11.70
Rate for Payer: BCBS MT Closed Plan Network	$12.35
Rate for Payer: BCBS MT HealthLink	$11.70
Rate for Payer: BCBS MT Medicare	$11.70
Rate for Payer: BCBS MT POS	$12.35
Rate for Payer: BCBS MT Traditional	$13.00
Rate for Payer: Cash Price	$11.70
Rate for Payer: Cigna Commercial	$12.35
Rate for Payer: Cigna Medicare	$11.70
Rate for Payer: Medicaid All Medicaid	$11.96
Rate for Payer: Medicare All Medicare	$9.10
Rate for Payer: Monida Allegiance	$12.35
Rate for Payer: Monida First Choice Health	$12.61
Rate for Payer: Monida Montana Health Co-op	$12.35
Rate for Payer: Monida PacificSource	$12.35

STRETCH BANDAGE 3'' STERILE

Facility

$13.00

Hospital Charge Code	80030027
Hospital Revenue Code	270
Min. Negotiated Rate	$9.10
Max. Negotiated Rate	$13.00
Rate for Payer: Aetna Commercial	$12.35
Rate for Payer: Aetna Medicare	$11.70
Rate for Payer: BCBS MT CHIP	$11.70
Rate for Payer: BCBS MT Closed Plan Network	$12.35
Rate for Payer: BCBS MT HealthLink	$11.70
Rate for Payer: BCBS MT Medicare	$11.70
Rate for Payer: BCBS MT POS	$12.35
Rate for Payer: BCBS MT Traditional	$13.00
Rate for Payer: Cash Price	$11.70
Rate for Payer: Cigna Commercial	$12.35
Rate for Payer: Cigna Medicare	$11.70
Rate for Payer: Medicaid All Medicaid	$11.96
Rate for Payer: Medicare All Medicare	$9.10
Rate for Payer: Monida Allegiance	$12.35
Rate for Payer: Monida First Choice Health	$12.61
Rate for Payer: Monida Montana Health Co-op	$12.35
Rate for Payer: Monida PacificSource	$12.35

STROMATOLYSER 4DL 5 LITERS

Facility

$104.50

Hospital Charge Code	90195077
Hospital Revenue Code	270
Min. Negotiated Rate	$73.15
Max. Negotiated Rate	$104.50
Rate for Payer: Aetna Commercial	$99.28
Rate for Payer: Aetna Medicare	$94.05
Rate for Payer: BCBS MT CHIP	$94.05
Rate for Payer: BCBS MT Closed Plan Network	$99.28
Rate for Payer: BCBS MT HealthLink	$94.05
Rate for Payer: BCBS MT Medicare	$94.05
Rate for Payer: BCBS MT POS	$99.28
Rate for Payer: BCBS MT Traditional	$104.50
Rate for Payer: Cash Price	$94.05
Rate for Payer: Cigna Commercial	$99.28
Rate for Payer: Cigna Medicare	$94.05
Rate for Payer: Medicaid All Medicaid	$96.14
Rate for Payer: Medicare All Medicare	$73.15
Rate for Payer: Monida Allegiance	$99.28
Rate for Payer: Monida First Choice Health	$101.36
Rate for Payer: Monida Montana Health Co-op	$99.28
Rate for Payer: Monida PacificSource	$99.28

STROMATOLYSER 4DL 5 LITERS

Facility

$104.50

Hospital Charge Code	90195077
Hospital Revenue Code	270
Min. Negotiated Rate	$73.15
Max. Negotiated Rate	$104.50
Rate for Payer: Aetna Commercial	$99.28
Rate for Payer: Aetna Medicare	$94.05
Rate for Payer: BCBS MT CHIP	$94.05
Rate for Payer: BCBS MT Closed Plan Network	$99.28
Rate for Payer: BCBS MT HealthLink	$94.05
Rate for Payer: BCBS MT Medicare	$94.05
Rate for Payer: BCBS MT POS	$99.28
Rate for Payer: BCBS MT Traditional	$104.50
Rate for Payer: Cash Price	$94.05
Rate for Payer: Cigna Commercial	$99.28
Rate for Payer: Cigna Medicare	$94.05
Rate for Payer: Medicaid All Medicaid	$96.14
Rate for Payer: Medicare All Medicare	$73.15
Rate for Payer: Monida Allegiance	$99.28
Rate for Payer: Monida First Choice Health	$101.36
Rate for Payer: Monida Montana Health Co-op	$99.28
Rate for Payer: Monida PacificSource	$99.28

ST SELF CARE HOME MGMT ADL EA 15 MIN

Facility

$105.00

Service Code	CPT 97535
Hospital Charge Code	6397535
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 SELF CARE HOME MGMT ADL EA 15 MIN

Facility

$105.00

Service Code	CPT 97535
Hospital Charge Code	6397535
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 SGD EVAL 1ST HR

Facility

$471.00

Service Code	CPT 92607
Hospital Charge Code	6392607
Hospital Revenue Code	440
Min. Negotiated Rate	$329.70
Max. Negotiated Rate	$471.00
Rate for Payer: Aetna Commercial	$447.45
Rate for Payer: Aetna Medicare	$423.90
Rate for Payer: BCBS MT CHIP	$423.90
Rate for Payer: BCBS MT Closed Plan Network	$447.45
Rate for Payer: BCBS MT HealthLink	$423.90
Rate for Payer: BCBS MT Medicare	$423.90
Rate for Payer: BCBS MT POS	$447.45
Rate for Payer: BCBS MT Traditional	$471.00
Rate for Payer: Cash Price	$423.90
Rate for Payer: Cigna Commercial	$447.45
Rate for Payer: Cigna Medicare	$423.90
Rate for Payer: Medicaid All Medicaid	$433.32
Rate for Payer: Medicare All Medicare	$329.70
Rate for Payer: Monida Allegiance	$447.45
Rate for Payer: Monida First Choice Health	$456.87
Rate for Payer: Monida Montana Health Co-op	$447.45
Rate for Payer: Monida PacificSource	$447.45

Know your out-of-pocket cost for care.

All Charges