Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

SUTURE REMOVAL KIT A49

Facility

$5.00

Hospital Charge Code	80030302
Hospital Revenue Code	270
Min. Negotiated Rate	$3.50
Max. Negotiated Rate	$5.00
Rate for Payer: Aetna Commercial	$4.75
Rate for Payer: Aetna Medicare	$4.50
Rate for Payer: BCBS MT CHIP	$4.50
Rate for Payer: BCBS MT Closed Plan Network	$4.75
Rate for Payer: BCBS MT HealthLink	$4.50
Rate for Payer: BCBS MT Medicare	$4.50
Rate for Payer: BCBS MT POS	$4.75
Rate for Payer: BCBS MT Traditional	$5.00
Rate for Payer: Cash Price	$4.50
Rate for Payer: Cigna Commercial	$4.75
Rate for Payer: Cigna Medicare	$4.50
Rate for Payer: Medicaid All Medicaid	$4.60
Rate for Payer: Medicare All Medicare	$3.50
Rate for Payer: Monida Allegiance	$4.75
Rate for Payer: Monida First Choice Health	$4.85
Rate for Payer: Monida Montana Health Co-op	$4.75
Rate for Payer: Monida PacificSource	$4.75

SUTURE REMOVAL KIT A49

Facility

$5.00

Hospital Charge Code	80030302
Hospital Revenue Code	270
Min. Negotiated Rate	$3.50
Max. Negotiated Rate	$5.00
Rate for Payer: Aetna Commercial	$4.75
Rate for Payer: Aetna Medicare	$4.50
Rate for Payer: BCBS MT CHIP	$4.50
Rate for Payer: BCBS MT Closed Plan Network	$4.75
Rate for Payer: BCBS MT HealthLink	$4.50
Rate for Payer: BCBS MT Medicare	$4.50
Rate for Payer: BCBS MT POS	$4.75
Rate for Payer: BCBS MT Traditional	$5.00
Rate for Payer: Cash Price	$4.50
Rate for Payer: Cigna Commercial	$4.75
Rate for Payer: Cigna Medicare	$4.50
Rate for Payer: Medicaid All Medicaid	$4.60
Rate for Payer: Medicare All Medicare	$3.50
Rate for Payer: Monida Allegiance	$4.75
Rate for Payer: Monida First Choice Health	$4.85
Rate for Payer: Monida Montana Health Co-op	$4.75
Rate for Payer: Monida PacificSource	$4.75

SUZETRIGINE TAB [50 MG] NF

Facility

$62.00

Service Code	HCPCS C9818
Hospital Charge Code	3007752
Hospital Revenue Code	250
Min. Negotiated Rate	$43.40
Max. Negotiated Rate	$62.00
Rate for Payer: Aetna Commercial	$58.90
Rate for Payer: Aetna Medicare	$55.80
Rate for Payer: BCBS MT CHIP	$55.80
Rate for Payer: BCBS MT Closed Plan Network	$58.90
Rate for Payer: BCBS MT HealthLink	$55.80
Rate for Payer: BCBS MT Medicare	$55.80
Rate for Payer: BCBS MT POS	$58.90
Rate for Payer: BCBS MT Traditional	$62.00
Rate for Payer: Cash Price	$55.80
Rate for Payer: Cigna Commercial	$58.90
Rate for Payer: Cigna Medicare	$55.80
Rate for Payer: Medicaid All Medicaid	$57.04
Rate for Payer: Medicare All Medicare	$43.40
Rate for Payer: Monida Allegiance	$58.90
Rate for Payer: Monida First Choice Health	$60.14
Rate for Payer: Monida Montana Health Co-op	$58.90
Rate for Payer: Monida PacificSource	$58.90

SUZETRIGINE TAB [50 MG] NF

Facility

$62.00

Service Code	HCPCS C9818
Hospital Charge Code	3007752
Hospital Revenue Code	250
Min. Negotiated Rate	$43.40
Max. Negotiated Rate	$62.00
Rate for Payer: Aetna Commercial	$58.90
Rate for Payer: Aetna Medicare	$55.80
Rate for Payer: BCBS MT CHIP	$55.80
Rate for Payer: BCBS MT Closed Plan Network	$58.90
Rate for Payer: BCBS MT HealthLink	$55.80
Rate for Payer: BCBS MT Medicare	$55.80
Rate for Payer: BCBS MT POS	$58.90
Rate for Payer: BCBS MT Traditional	$62.00
Rate for Payer: Cash Price	$55.80
Rate for Payer: Cigna Commercial	$58.90
Rate for Payer: Cigna Medicare	$55.80
Rate for Payer: Medicaid All Medicaid	$57.04
Rate for Payer: Medicare All Medicare	$43.40
Rate for Payer: Monida Allegiance	$58.90
Rate for Payer: Monida First Choice Health	$60.14
Rate for Payer: Monida Montana Health Co-op	$58.90
Rate for Payer: Monida PacificSource	$58.90

SWING BED

Facility

$1,447.00

Hospital Charge Code	300003
Hospital Revenue Code	120
Min. Negotiated Rate	$1,012.90
Max. Negotiated Rate	$1,447.00
Rate for Payer: Aetna Commercial	$1,374.65
Rate for Payer: Aetna Medicare	$1,302.30
Rate for Payer: BCBS MT CHIP	$1,302.30
Rate for Payer: BCBS MT Closed Plan Network	$1,374.65
Rate for Payer: BCBS MT HealthLink	$1,302.30
Rate for Payer: BCBS MT Medicare	$1,302.30
Rate for Payer: BCBS MT POS	$1,374.65
Rate for Payer: BCBS MT Traditional	$1,447.00
Rate for Payer: Cash Price	$1,302.30
Rate for Payer: Cigna Commercial	$1,374.65
Rate for Payer: Cigna Medicare	$1,302.30
Rate for Payer: Medicaid All Medicaid	$1,331.24
Rate for Payer: Medicare All Medicare	$1,012.90
Rate for Payer: Monida Allegiance	$1,374.65
Rate for Payer: Monida First Choice Health	$1,403.59
Rate for Payer: Monida Montana Health Co-op	$1,374.65
Rate for Payer: Monida PacificSource	$1,374.65

SYNCH AUDIO-ONLY EST HIGH 40

Facility

$245.00

Service Code	CPT 98015
Hospital Charge Code	8098015
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-ONLY EST HIGH 40

Facility

$245.00

Service Code	CPT 98015
Hospital Charge Code	8098015
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-ONLY EST LOW 20

Facility

$112.00

Service Code	CPT 98013
Hospital Charge Code	8098013
Hospital Revenue Code	521
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

SYNCH AUDIO-ONLY EST LOW 20

Facility

$112.00

Service Code	CPT 98013
Hospital Charge Code	8098013
Hospital Revenue Code	521
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

SYNCH AUDIO-ONLY EST MOD 30

Facility

$166.00

Service Code	CPT 98014
Hospital Charge Code	8098014
Hospital Revenue Code	521
Min. Negotiated Rate	$116.20
Max. Negotiated Rate	$166.00
Rate for Payer: Aetna Commercial	$157.70
Rate for Payer: Aetna Medicare	$149.40
Rate for Payer: BCBS MT CHIP	$149.40
Rate for Payer: BCBS MT Closed Plan Network	$157.70
Rate for Payer: BCBS MT HealthLink	$149.40
Rate for Payer: BCBS MT Medicare	$149.40
Rate for Payer: BCBS MT POS	$157.70
Rate for Payer: BCBS MT Traditional	$166.00
Rate for Payer: Cash Price	$149.40
Rate for Payer: Cigna Commercial	$157.70
Rate for Payer: Cigna Medicare	$149.40
Rate for Payer: Medicaid All Medicaid	$152.72
Rate for Payer: Medicare All Medicare	$116.20
Rate for Payer: Monida Allegiance	$157.70
Rate for Payer: Monida First Choice Health	$161.02
Rate for Payer: Monida Montana Health Co-op	$157.70
Rate for Payer: Monida PacificSource	$157.70

SYNCH AUDIO-ONLY EST MOD 30

Facility

$166.00

Service Code	CPT 98014
Hospital Charge Code	8098014
Hospital Revenue Code	521
Min. Negotiated Rate	$116.20
Max. Negotiated Rate	$166.00
Rate for Payer: Aetna Commercial	$157.70
Rate for Payer: Aetna Medicare	$149.40
Rate for Payer: BCBS MT CHIP	$149.40
Rate for Payer: BCBS MT Closed Plan Network	$157.70
Rate for Payer: BCBS MT HealthLink	$149.40
Rate for Payer: BCBS MT Medicare	$149.40
Rate for Payer: BCBS MT POS	$157.70
Rate for Payer: BCBS MT Traditional	$166.00
Rate for Payer: Cash Price	$149.40
Rate for Payer: Cigna Commercial	$157.70
Rate for Payer: Cigna Medicare	$149.40
Rate for Payer: Medicaid All Medicaid	$152.72
Rate for Payer: Medicare All Medicare	$116.20
Rate for Payer: Monida Allegiance	$157.70
Rate for Payer: Monida First Choice Health	$161.02
Rate for Payer: Monida Montana Health Co-op	$157.70
Rate for Payer: Monida PacificSource	$157.70

SYNCH AUDIO-ONLY EST SF 10

Facility

$62.00

Service Code	CPT 98012
Hospital Charge Code	8098012
Hospital Revenue Code	521
Min. Negotiated Rate	$43.40
Max. Negotiated Rate	$62.00
Rate for Payer: Aetna Commercial	$58.90
Rate for Payer: Aetna Medicare	$55.80
Rate for Payer: BCBS MT CHIP	$55.80
Rate for Payer: BCBS MT Closed Plan Network	$58.90
Rate for Payer: BCBS MT HealthLink	$55.80
Rate for Payer: BCBS MT Medicare	$55.80
Rate for Payer: BCBS MT POS	$58.90
Rate for Payer: BCBS MT Traditional	$62.00
Rate for Payer: Cash Price	$55.80
Rate for Payer: Cigna Commercial	$58.90
Rate for Payer: Cigna Medicare	$55.80
Rate for Payer: Medicaid All Medicaid	$57.04
Rate for Payer: Medicare All Medicare	$43.40
Rate for Payer: Monida Allegiance	$58.90
Rate for Payer: Monida First Choice Health	$60.14
Rate for Payer: Monida Montana Health Co-op	$58.90
Rate for Payer: Monida PacificSource	$58.90

SYNCH AUDIO-ONLY EST SF 10

Facility

$62.00

Service Code	CPT 98012
Hospital Charge Code	8098012
Hospital Revenue Code	521
Min. Negotiated Rate	$43.40
Max. Negotiated Rate	$62.00
Rate for Payer: Aetna Commercial	$58.90
Rate for Payer: Aetna Medicare	$55.80
Rate for Payer: BCBS MT CHIP	$55.80
Rate for Payer: BCBS MT Closed Plan Network	$58.90
Rate for Payer: BCBS MT HealthLink	$55.80
Rate for Payer: BCBS MT Medicare	$55.80
Rate for Payer: BCBS MT POS	$58.90
Rate for Payer: BCBS MT Traditional	$62.00
Rate for Payer: Cash Price	$55.80
Rate for Payer: Cigna Commercial	$58.90
Rate for Payer: Cigna Medicare	$55.80
Rate for Payer: Medicaid All Medicaid	$57.04
Rate for Payer: Medicare All Medicare	$43.40
Rate for Payer: Monida Allegiance	$58.90
Rate for Payer: Monida First Choice Health	$60.14
Rate for Payer: Monida Montana Health Co-op	$58.90
Rate for Payer: Monida PacificSource	$58.90

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 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

Know your out-of-pocket cost for care.

All Charges