Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

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

SYSMEX AUTO CELL CLEANER 20ML

Facility

$24.48

Hospital Charge Code	90197164
Hospital Revenue Code	270
Min. Negotiated Rate	$17.14
Max. Negotiated Rate	$24.48
Rate for Payer: Aetna Commercial	$23.26
Rate for Payer: Aetna Medicare	$22.03
Rate for Payer: BCBS MT CHIP	$22.03
Rate for Payer: BCBS MT Closed Plan Network	$23.26
Rate for Payer: BCBS MT HealthLink	$22.03
Rate for Payer: BCBS MT Medicare	$22.03
Rate for Payer: BCBS MT POS	$23.26
Rate for Payer: BCBS MT Traditional	$24.48
Rate for Payer: Cash Price	$22.03
Rate for Payer: Cigna Commercial	$23.26
Rate for Payer: Cigna Medicare	$22.03
Rate for Payer: Medicaid All Medicaid	$22.52
Rate for Payer: Medicare All Medicare	$17.14
Rate for Payer: Monida Allegiance	$23.26
Rate for Payer: Monida First Choice Health	$23.75
Rate for Payer: Monida Montana Health Co-op	$23.26
Rate for Payer: Monida PacificSource	$23.26

SYSMEX AUTO CELL CLEANER 20ML

Facility

$24.48

Hospital Charge Code	90197164
Hospital Revenue Code	270
Min. Negotiated Rate	$17.14
Max. Negotiated Rate	$24.48
Rate for Payer: Aetna Commercial	$23.26
Rate for Payer: Aetna Medicare	$22.03
Rate for Payer: BCBS MT CHIP	$22.03
Rate for Payer: BCBS MT Closed Plan Network	$23.26
Rate for Payer: BCBS MT HealthLink	$22.03
Rate for Payer: BCBS MT Medicare	$22.03
Rate for Payer: BCBS MT POS	$23.26
Rate for Payer: BCBS MT Traditional	$24.48
Rate for Payer: Cash Price	$22.03
Rate for Payer: Cigna Commercial	$23.26
Rate for Payer: Cigna Medicare	$22.03
Rate for Payer: Medicaid All Medicaid	$22.52
Rate for Payer: Medicare All Medicare	$17.14
Rate for Payer: Monida Allegiance	$23.26
Rate for Payer: Monida First Choice Health	$23.75
Rate for Payer: Monida Montana Health Co-op	$23.26
Rate for Payer: Monida PacificSource	$23.26

SYSMEX XN450 ANALYZER

Facility

$44,500.00

Hospital Charge Code	90197160
Hospital Revenue Code	270
Min. Negotiated Rate	$31,150.00
Max. Negotiated Rate	$44,500.00
Rate for Payer: Aetna Commercial	$42,275.00
Rate for Payer: Aetna Medicare	$40,050.00
Rate for Payer: BCBS MT CHIP	$40,050.00
Rate for Payer: BCBS MT Closed Plan Network	$42,275.00
Rate for Payer: BCBS MT HealthLink	$40,050.00
Rate for Payer: BCBS MT Medicare	$40,050.00
Rate for Payer: BCBS MT POS	$42,275.00
Rate for Payer: BCBS MT Traditional	$44,500.00
Rate for Payer: Cash Price	$40,050.00
Rate for Payer: Cigna Commercial	$42,275.00
Rate for Payer: Cigna Medicare	$40,050.00
Rate for Payer: Medicaid All Medicaid	$40,940.00
Rate for Payer: Medicare All Medicare	$31,150.00
Rate for Payer: Monida Allegiance	$42,275.00
Rate for Payer: Monida First Choice Health	$43,165.00
Rate for Payer: Monida Montana Health Co-op	$42,275.00
Rate for Payer: Monida PacificSource	$42,275.00

SYSMEX XN450 ANALYZER

Facility

$44,500.00

Hospital Charge Code	90197160
Hospital Revenue Code	270
Min. Negotiated Rate	$31,150.00
Max. Negotiated Rate	$44,500.00
Rate for Payer: Aetna Commercial	$42,275.00
Rate for Payer: Aetna Medicare	$40,050.00
Rate for Payer: BCBS MT CHIP	$40,050.00
Rate for Payer: BCBS MT Closed Plan Network	$42,275.00
Rate for Payer: BCBS MT HealthLink	$40,050.00
Rate for Payer: BCBS MT Medicare	$40,050.00
Rate for Payer: BCBS MT POS	$42,275.00
Rate for Payer: BCBS MT Traditional	$44,500.00
Rate for Payer: Cash Price	$40,050.00
Rate for Payer: Cigna Commercial	$42,275.00
Rate for Payer: Cigna Medicare	$40,050.00
Rate for Payer: Medicaid All Medicaid	$40,940.00
Rate for Payer: Medicare All Medicare	$31,150.00
Rate for Payer: Monida Allegiance	$42,275.00
Rate for Payer: Monida First Choice Health	$43,165.00
Rate for Payer: Monida Montana Health Co-op	$42,275.00
Rate for Payer: Monida PacificSource	$42,275.00

SYSMEX XS PIERCER SET

Facility

$448.41

Hospital Charge Code	90197085
Hospital Revenue Code	270
Min. Negotiated Rate	$313.89
Max. Negotiated Rate	$448.41
Rate for Payer: Aetna Commercial	$425.99
Rate for Payer: Aetna Medicare	$403.57
Rate for Payer: BCBS MT CHIP	$403.57
Rate for Payer: BCBS MT Closed Plan Network	$425.99
Rate for Payer: BCBS MT HealthLink	$403.57
Rate for Payer: BCBS MT Medicare	$403.57
Rate for Payer: BCBS MT POS	$425.99
Rate for Payer: BCBS MT Traditional	$448.41
Rate for Payer: Cash Price	$403.57
Rate for Payer: Cigna Commercial	$425.99
Rate for Payer: Cigna Medicare	$403.57
Rate for Payer: Medicaid All Medicaid	$412.54
Rate for Payer: Medicare All Medicare	$313.89
Rate for Payer: Monida Allegiance	$425.99
Rate for Payer: Monida First Choice Health	$434.96
Rate for Payer: Monida Montana Health Co-op	$425.99
Rate for Payer: Monida PacificSource	$425.99

SYSMEX XS PIERCER SET

Facility

$448.41

Hospital Charge Code	90197085
Hospital Revenue Code	270
Min. Negotiated Rate	$313.89
Max. Negotiated Rate	$448.41
Rate for Payer: Aetna Commercial	$425.99
Rate for Payer: Aetna Medicare	$403.57
Rate for Payer: BCBS MT CHIP	$403.57
Rate for Payer: BCBS MT Closed Plan Network	$425.99
Rate for Payer: BCBS MT HealthLink	$403.57
Rate for Payer: BCBS MT Medicare	$403.57
Rate for Payer: BCBS MT POS	$425.99
Rate for Payer: BCBS MT Traditional	$448.41
Rate for Payer: Cash Price	$403.57
Rate for Payer: Cigna Commercial	$425.99
Rate for Payer: Cigna Medicare	$403.57
Rate for Payer: Medicaid All Medicaid	$412.54
Rate for Payer: Medicare All Medicare	$313.89
Rate for Payer: Monida Allegiance	$425.99
Rate for Payer: Monida First Choice Health	$434.96
Rate for Payer: Monida Montana Health Co-op	$425.99
Rate for Payer: Monida PacificSource	$425.99

T3, FREE (BCL 8995)

Facility

$32.00

Service Code	CPT 84481
Hospital Charge Code	4084481
Hospital Revenue Code	301
Min. Negotiated Rate	$22.40
Max. Negotiated Rate	$32.00
Rate for Payer: Aetna Commercial	$30.40
Rate for Payer: Aetna Medicare	$28.80
Rate for Payer: BCBS MT CHIP	$28.80
Rate for Payer: BCBS MT Closed Plan Network	$30.40
Rate for Payer: BCBS MT HealthLink	$28.80
Rate for Payer: BCBS MT Medicare	$28.80
Rate for Payer: BCBS MT POS	$30.40
Rate for Payer: BCBS MT Traditional	$32.00
Rate for Payer: Cash Price	$28.80
Rate for Payer: Cigna Commercial	$30.40
Rate for Payer: Cigna Medicare	$28.80
Rate for Payer: Medicaid All Medicaid	$29.44
Rate for Payer: Medicare All Medicare	$22.40
Rate for Payer: Monida Allegiance	$30.40
Rate for Payer: Monida First Choice Health	$31.04
Rate for Payer: Monida Montana Health Co-op	$30.40
Rate for Payer: Monida PacificSource	$30.40

T3, FREE (BCL 8995)

Facility

$32.00

Service Code	CPT 84481
Hospital Charge Code	4084481
Hospital Revenue Code	301
Min. Negotiated Rate	$22.40
Max. Negotiated Rate	$32.00
Rate for Payer: Aetna Commercial	$30.40
Rate for Payer: Aetna Medicare	$28.80
Rate for Payer: BCBS MT CHIP	$28.80
Rate for Payer: BCBS MT Closed Plan Network	$30.40
Rate for Payer: BCBS MT HealthLink	$28.80
Rate for Payer: BCBS MT Medicare	$28.80
Rate for Payer: BCBS MT POS	$30.40
Rate for Payer: BCBS MT Traditional	$32.00
Rate for Payer: Cash Price	$28.80
Rate for Payer: Cigna Commercial	$30.40
Rate for Payer: Cigna Medicare	$28.80
Rate for Payer: Medicaid All Medicaid	$29.44
Rate for Payer: Medicare All Medicare	$22.40
Rate for Payer: Monida Allegiance	$30.40
Rate for Payer: Monida First Choice Health	$31.04
Rate for Payer: Monida Montana Health Co-op	$30.40
Rate for Payer: Monida PacificSource	$30.40

T3, REVERSE (070104)

Facility

$516.00

Service Code	CPT 84482
Hospital Charge Code	4084482
Hospital Revenue Code	301
Min. Negotiated Rate	$361.20
Max. Negotiated Rate	$516.00
Rate for Payer: Aetna Commercial	$490.20
Rate for Payer: Aetna Medicare	$464.40
Rate for Payer: BCBS MT CHIP	$464.40
Rate for Payer: BCBS MT Closed Plan Network	$490.20
Rate for Payer: BCBS MT HealthLink	$464.40
Rate for Payer: BCBS MT Medicare	$464.40
Rate for Payer: BCBS MT POS	$490.20
Rate for Payer: BCBS MT Traditional	$516.00
Rate for Payer: Cash Price	$464.40
Rate for Payer: Cigna Commercial	$490.20
Rate for Payer: Cigna Medicare	$464.40
Rate for Payer: Medicaid All Medicaid	$474.72
Rate for Payer: Medicare All Medicare	$361.20
Rate for Payer: Monida Allegiance	$490.20
Rate for Payer: Monida First Choice Health	$500.52
Rate for Payer: Monida Montana Health Co-op	$490.20
Rate for Payer: Monida PacificSource	$490.20

T3, REVERSE (070104)

Facility

$516.00

Service Code	CPT 84482
Hospital Charge Code	4084482
Hospital Revenue Code	301
Min. Negotiated Rate	$361.20
Max. Negotiated Rate	$516.00
Rate for Payer: Aetna Commercial	$490.20
Rate for Payer: Aetna Medicare	$464.40
Rate for Payer: BCBS MT CHIP	$464.40
Rate for Payer: BCBS MT Closed Plan Network	$490.20
Rate for Payer: BCBS MT HealthLink	$464.40
Rate for Payer: BCBS MT Medicare	$464.40
Rate for Payer: BCBS MT POS	$490.20
Rate for Payer: BCBS MT Traditional	$516.00
Rate for Payer: Cash Price	$464.40
Rate for Payer: Cigna Commercial	$490.20
Rate for Payer: Cigna Medicare	$464.40
Rate for Payer: Medicaid All Medicaid	$474.72
Rate for Payer: Medicare All Medicare	$361.20
Rate for Payer: Monida Allegiance	$490.20
Rate for Payer: Monida First Choice Health	$500.52
Rate for Payer: Monida Montana Health Co-op	$490.20
Rate for Payer: Monida PacificSource	$490.20

T3, TOTAL (002188)

Facility

$71.00

Service Code	CPT 84480
Hospital Charge Code	4084480
Hospital Revenue Code	301
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

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