Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

TSH

Facility

$167.00

Service Code	CPT 84443
Hospital Charge Code	4084443
Hospital Revenue Code	301
Min. Negotiated Rate	$116.90
Max. Negotiated Rate	$167.00
Rate for Payer: Aetna Commercial	$158.65
Rate for Payer: Aetna Medicare	$150.30
Rate for Payer: BCBS MT CHIP	$150.30
Rate for Payer: BCBS MT Closed Plan Network	$158.65
Rate for Payer: BCBS MT HealthLink	$150.30
Rate for Payer: BCBS MT Medicare	$150.30
Rate for Payer: BCBS MT POS	$158.65
Rate for Payer: BCBS MT Traditional	$167.00
Rate for Payer: Cash Price	$150.30
Rate for Payer: Cigna Commercial	$158.65
Rate for Payer: Cigna Medicare	$150.30
Rate for Payer: Medicaid All Medicaid	$153.64
Rate for Payer: Medicare All Medicare	$116.90
Rate for Payer: Monida Allegiance	$158.65
Rate for Payer: Monida First Choice Health	$161.99
Rate for Payer: Monida Montana Health Co-op	$158.65
Rate for Payer: Monida PacificSource	$158.65

TSH

Facility

$167.00

Service Code	CPT 84443
Hospital Charge Code	4084443
Hospital Revenue Code	301
Min. Negotiated Rate	$116.90
Max. Negotiated Rate	$167.00
Rate for Payer: Aetna Commercial	$158.65
Rate for Payer: Aetna Medicare	$150.30
Rate for Payer: BCBS MT CHIP	$150.30
Rate for Payer: BCBS MT Closed Plan Network	$158.65
Rate for Payer: BCBS MT HealthLink	$150.30
Rate for Payer: BCBS MT Medicare	$150.30
Rate for Payer: BCBS MT POS	$158.65
Rate for Payer: BCBS MT Traditional	$167.00
Rate for Payer: Cash Price	$150.30
Rate for Payer: Cigna Commercial	$158.65
Rate for Payer: Cigna Medicare	$150.30
Rate for Payer: Medicaid All Medicaid	$153.64
Rate for Payer: Medicare All Medicare	$116.90
Rate for Payer: Monida Allegiance	$158.65
Rate for Payer: Monida First Choice Health	$161.99
Rate for Payer: Monida Montana Health Co-op	$158.65
Rate for Payer: Monida PacificSource	$158.65

TSH W/ REFLEX

Facility

$167.00

Service Code	CPT 84443
Hospital Charge Code	4044431
Hospital Revenue Code	301
Min. Negotiated Rate	$116.90
Max. Negotiated Rate	$167.00
Rate for Payer: Aetna Commercial	$158.65
Rate for Payer: Aetna Medicare	$150.30
Rate for Payer: BCBS MT CHIP	$150.30
Rate for Payer: BCBS MT Closed Plan Network	$158.65
Rate for Payer: BCBS MT HealthLink	$150.30
Rate for Payer: BCBS MT Medicare	$150.30
Rate for Payer: BCBS MT POS	$158.65
Rate for Payer: BCBS MT Traditional	$167.00
Rate for Payer: Cash Price	$150.30
Rate for Payer: Cigna Commercial	$158.65
Rate for Payer: Cigna Medicare	$150.30
Rate for Payer: Medicaid All Medicaid	$153.64
Rate for Payer: Medicare All Medicare	$116.90
Rate for Payer: Monida Allegiance	$158.65
Rate for Payer: Monida First Choice Health	$161.99
Rate for Payer: Monida Montana Health Co-op	$158.65
Rate for Payer: Monida PacificSource	$158.65

TSH W/ REFLEX

Facility

$167.00

Service Code	CPT 84443
Hospital Charge Code	4044431
Hospital Revenue Code	301
Min. Negotiated Rate	$116.90
Max. Negotiated Rate	$167.00
Rate for Payer: Aetna Commercial	$158.65
Rate for Payer: Aetna Medicare	$150.30
Rate for Payer: BCBS MT CHIP	$150.30
Rate for Payer: BCBS MT Closed Plan Network	$158.65
Rate for Payer: BCBS MT HealthLink	$150.30
Rate for Payer: BCBS MT Medicare	$150.30
Rate for Payer: BCBS MT POS	$158.65
Rate for Payer: BCBS MT Traditional	$167.00
Rate for Payer: Cash Price	$150.30
Rate for Payer: Cigna Commercial	$158.65
Rate for Payer: Cigna Medicare	$150.30
Rate for Payer: Medicaid All Medicaid	$153.64
Rate for Payer: Medicare All Medicare	$116.90
Rate for Payer: Monida Allegiance	$158.65
Rate for Payer: Monida First Choice Health	$161.99
Rate for Payer: Monida Montana Health Co-op	$158.65
Rate for Payer: Monida PacificSource	$158.65

TTG ANTIBODY, IGA (164640)

Facility

$79.00

Service Code	CPT 86364
Hospital Charge Code	4000071
Hospital Revenue Code	301
Min. Negotiated Rate	$55.30
Max. Negotiated Rate	$79.00
Rate for Payer: Aetna Commercial	$75.05
Rate for Payer: Aetna Medicare	$71.10
Rate for Payer: BCBS MT CHIP	$71.10
Rate for Payer: BCBS MT Closed Plan Network	$75.05
Rate for Payer: BCBS MT HealthLink	$71.10
Rate for Payer: BCBS MT Medicare	$71.10
Rate for Payer: BCBS MT POS	$75.05
Rate for Payer: BCBS MT Traditional	$79.00
Rate for Payer: Cash Price	$71.10
Rate for Payer: Cigna Commercial	$75.05
Rate for Payer: Cigna Medicare	$71.10
Rate for Payer: Medicaid All Medicaid	$72.68
Rate for Payer: Medicare All Medicare	$55.30
Rate for Payer: Monida Allegiance	$75.05
Rate for Payer: Monida First Choice Health	$76.63
Rate for Payer: Monida Montana Health Co-op	$75.05
Rate for Payer: Monida PacificSource	$75.05

TTG ANTIBODY, IGA (164640)

Facility

$79.00

Service Code	CPT 86364
Hospital Charge Code	4000071
Hospital Revenue Code	301
Min. Negotiated Rate	$55.30
Max. Negotiated Rate	$79.00
Rate for Payer: Aetna Commercial	$75.05
Rate for Payer: Aetna Medicare	$71.10
Rate for Payer: BCBS MT CHIP	$71.10
Rate for Payer: BCBS MT Closed Plan Network	$75.05
Rate for Payer: BCBS MT HealthLink	$71.10
Rate for Payer: BCBS MT Medicare	$71.10
Rate for Payer: BCBS MT POS	$75.05
Rate for Payer: BCBS MT Traditional	$79.00
Rate for Payer: Cash Price	$71.10
Rate for Payer: Cigna Commercial	$75.05
Rate for Payer: Cigna Medicare	$71.10
Rate for Payer: Medicaid All Medicaid	$72.68
Rate for Payer: Medicare All Medicare	$55.30
Rate for Payer: Monida Allegiance	$75.05
Rate for Payer: Monida First Choice Health	$76.63
Rate for Payer: Monida Montana Health Co-op	$75.05
Rate for Payer: Monida PacificSource	$75.05

TTG ANTIBODY, IGG (164988)

Facility

$84.00

Service Code	CPT 86364
Hospital Charge Code	4000072
Hospital Revenue Code	301
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

TTG ANTIBODY, IGG (164988)

Facility

$84.00

Service Code	CPT 86364
Hospital Charge Code	4000072
Hospital Revenue Code	301
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

TUBERCULOSIS TEST INTRADERMAL

Facility

$56.00

Service Code	CPT 86580
Hospital Charge Code	3000492
Hospital Revenue Code	302
Min. Negotiated Rate	$39.20
Max. Negotiated Rate	$56.00
Rate for Payer: Aetna Commercial	$53.20
Rate for Payer: Aetna Medicare	$50.40
Rate for Payer: BCBS MT CHIP	$50.40
Rate for Payer: BCBS MT Closed Plan Network	$53.20
Rate for Payer: BCBS MT HealthLink	$50.40
Rate for Payer: BCBS MT Medicare	$50.40
Rate for Payer: BCBS MT POS	$53.20
Rate for Payer: BCBS MT Traditional	$56.00
Rate for Payer: Cash Price	$50.40
Rate for Payer: Cigna Commercial	$53.20
Rate for Payer: Cigna Medicare	$50.40
Rate for Payer: Medicaid All Medicaid	$51.52
Rate for Payer: Medicare All Medicare	$39.20
Rate for Payer: Monida Allegiance	$53.20
Rate for Payer: Monida First Choice Health	$54.32
Rate for Payer: Monida Montana Health Co-op	$53.20
Rate for Payer: Monida PacificSource	$53.20

TUBERCULOSIS TEST INTRADERMAL

Facility

$56.00

Service Code	CPT 86580
Hospital Charge Code	3000492
Hospital Revenue Code	302
Min. Negotiated Rate	$39.20
Max. Negotiated Rate	$56.00
Rate for Payer: Aetna Commercial	$53.20
Rate for Payer: Aetna Medicare	$50.40
Rate for Payer: BCBS MT CHIP	$50.40
Rate for Payer: BCBS MT Closed Plan Network	$53.20
Rate for Payer: BCBS MT HealthLink	$50.40
Rate for Payer: BCBS MT Medicare	$50.40
Rate for Payer: BCBS MT POS	$53.20
Rate for Payer: BCBS MT Traditional	$56.00
Rate for Payer: Cash Price	$50.40
Rate for Payer: Cigna Commercial	$53.20
Rate for Payer: Cigna Medicare	$50.40
Rate for Payer: Medicaid All Medicaid	$51.52
Rate for Payer: Medicare All Medicare	$39.20
Rate for Payer: Monida Allegiance	$53.20
Rate for Payer: Monida First Choice Health	$54.32
Rate for Payer: Monida Montana Health Co-op	$53.20
Rate for Payer: Monida PacificSource	$53.20

TUBERSOL PPD INJ [5 TU/0.1 ML]

Facility

$38.00

Service Code	CPT 86580
Hospital Charge Code	3000463
Hospital Revenue Code	302
Min. Negotiated Rate	$26.60
Max. Negotiated Rate	$38.00
Rate for Payer: Aetna Commercial	$36.10
Rate for Payer: Aetna Medicare	$34.20
Rate for Payer: BCBS MT CHIP	$34.20
Rate for Payer: BCBS MT Closed Plan Network	$36.10
Rate for Payer: BCBS MT HealthLink	$34.20
Rate for Payer: BCBS MT Medicare	$34.20
Rate for Payer: BCBS MT POS	$36.10
Rate for Payer: BCBS MT Traditional	$38.00
Rate for Payer: Cash Price	$34.20
Rate for Payer: Cigna Commercial	$36.10
Rate for Payer: Cigna Medicare	$34.20
Rate for Payer: Medicaid All Medicaid	$34.96
Rate for Payer: Medicare All Medicare	$26.60
Rate for Payer: Monida Allegiance	$36.10
Rate for Payer: Monida First Choice Health	$36.86
Rate for Payer: Monida Montana Health Co-op	$36.10
Rate for Payer: Monida PacificSource	$36.10

TUBERSOL PPD INJ [5 TU/0.1 ML]

Facility

$38.00

Service Code	CPT 86580
Hospital Charge Code	3000463
Hospital Revenue Code	302
Min. Negotiated Rate	$26.60
Max. Negotiated Rate	$38.00
Rate for Payer: Aetna Commercial	$36.10
Rate for Payer: Aetna Medicare	$34.20
Rate for Payer: BCBS MT CHIP	$34.20
Rate for Payer: BCBS MT Closed Plan Network	$36.10
Rate for Payer: BCBS MT HealthLink	$34.20
Rate for Payer: BCBS MT Medicare	$34.20
Rate for Payer: BCBS MT POS	$36.10
Rate for Payer: BCBS MT Traditional	$38.00
Rate for Payer: Cash Price	$34.20
Rate for Payer: Cigna Commercial	$36.10
Rate for Payer: Cigna Medicare	$34.20
Rate for Payer: Medicaid All Medicaid	$34.96
Rate for Payer: Medicare All Medicare	$26.60
Rate for Payer: Monida Allegiance	$36.10
Rate for Payer: Monida First Choice Health	$36.86
Rate for Payer: Monida Montana Health Co-op	$36.10
Rate for Payer: Monida PacificSource	$36.10

TUBING FILTER

Facility

$59.00

Hospital Charge Code	80030208
Hospital Revenue Code	270
Min. Negotiated Rate	$41.30
Max. Negotiated Rate	$59.00
Rate for Payer: Aetna Commercial	$56.05
Rate for Payer: Aetna Medicare	$53.10
Rate for Payer: BCBS MT CHIP	$53.10
Rate for Payer: BCBS MT Closed Plan Network	$56.05
Rate for Payer: BCBS MT HealthLink	$53.10
Rate for Payer: BCBS MT Medicare	$53.10
Rate for Payer: BCBS MT POS	$56.05
Rate for Payer: BCBS MT Traditional	$59.00
Rate for Payer: Cash Price	$53.10
Rate for Payer: Cigna Commercial	$56.05
Rate for Payer: Cigna Medicare	$53.10
Rate for Payer: Medicaid All Medicaid	$54.28
Rate for Payer: Medicare All Medicare	$41.30
Rate for Payer: Monida Allegiance	$56.05
Rate for Payer: Monida First Choice Health	$57.23
Rate for Payer: Monida Montana Health Co-op	$56.05
Rate for Payer: Monida PacificSource	$56.05

TUBING FILTER

Facility

$59.00

Hospital Charge Code	80030208
Hospital Revenue Code	270
Min. Negotiated Rate	$41.30
Max. Negotiated Rate	$59.00
Rate for Payer: Aetna Commercial	$56.05
Rate for Payer: Aetna Medicare	$53.10
Rate for Payer: BCBS MT CHIP	$53.10
Rate for Payer: BCBS MT Closed Plan Network	$56.05
Rate for Payer: BCBS MT HealthLink	$53.10
Rate for Payer: BCBS MT Medicare	$53.10
Rate for Payer: BCBS MT POS	$56.05
Rate for Payer: BCBS MT Traditional	$59.00
Rate for Payer: Cash Price	$53.10
Rate for Payer: Cigna Commercial	$56.05
Rate for Payer: Cigna Medicare	$53.10
Rate for Payer: Medicaid All Medicaid	$54.28
Rate for Payer: Medicare All Medicare	$41.30
Rate for Payer: Monida Allegiance	$56.05
Rate for Payer: Monida First Choice Health	$57.23
Rate for Payer: Monida Montana Health Co-op	$56.05
Rate for Payer: Monida PacificSource	$56.05

TUBING PRIMARY HOSPIRA PLUM

Facility

$27.00

Hospital Charge Code	80030897
Hospital Revenue Code	270
Min. Negotiated Rate	$18.90
Max. Negotiated Rate	$27.00
Rate for Payer: Aetna Commercial	$25.65
Rate for Payer: Aetna Medicare	$24.30
Rate for Payer: BCBS MT CHIP	$24.30
Rate for Payer: BCBS MT Closed Plan Network	$25.65
Rate for Payer: BCBS MT HealthLink	$24.30
Rate for Payer: BCBS MT Medicare	$24.30
Rate for Payer: BCBS MT POS	$25.65
Rate for Payer: BCBS MT Traditional	$27.00
Rate for Payer: Cash Price	$24.30
Rate for Payer: Cigna Commercial	$25.65
Rate for Payer: Cigna Medicare	$24.30
Rate for Payer: Medicaid All Medicaid	$24.84
Rate for Payer: Medicare All Medicare	$18.90
Rate for Payer: Monida Allegiance	$25.65
Rate for Payer: Monida First Choice Health	$26.19
Rate for Payer: Monida Montana Health Co-op	$25.65
Rate for Payer: Monida PacificSource	$25.65

TUBING PRIMARY HOSPIRA PLUM

Facility

$27.00

Hospital Charge Code	80030897
Hospital Revenue Code	270
Min. Negotiated Rate	$18.90
Max. Negotiated Rate	$27.00
Rate for Payer: Aetna Commercial	$25.65
Rate for Payer: Aetna Medicare	$24.30
Rate for Payer: BCBS MT CHIP	$24.30
Rate for Payer: BCBS MT Closed Plan Network	$25.65
Rate for Payer: BCBS MT HealthLink	$24.30
Rate for Payer: BCBS MT Medicare	$24.30
Rate for Payer: BCBS MT POS	$25.65
Rate for Payer: BCBS MT Traditional	$27.00
Rate for Payer: Cash Price	$24.30
Rate for Payer: Cigna Commercial	$25.65
Rate for Payer: Cigna Medicare	$24.30
Rate for Payer: Medicaid All Medicaid	$24.84
Rate for Payer: Medicare All Medicare	$18.90
Rate for Payer: Monida Allegiance	$25.65
Rate for Payer: Monida First Choice Health	$26.19
Rate for Payer: Monida Montana Health Co-op	$25.65
Rate for Payer: Monida PacificSource	$25.65

TUBING SECONDARY HOSPIRA PLUM

Facility

$13.00

Hospital Charge Code	90030898
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

TUBING SECONDARY HOSPIRA PLUM

Facility

$13.00

Hospital Charge Code	90030898
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

TUCKS MEDICATED COOLING PADS

Facility

$12.45

Hospital Charge Code	3007354
Hospital Revenue Code	250
Min. Negotiated Rate	$8.71
Max. Negotiated Rate	$12.45
Rate for Payer: Aetna Commercial	$11.83
Rate for Payer: Aetna Medicare	$11.21
Rate for Payer: BCBS MT CHIP	$11.21
Rate for Payer: BCBS MT Closed Plan Network	$11.83
Rate for Payer: BCBS MT HealthLink	$11.21
Rate for Payer: BCBS MT Medicare	$11.21
Rate for Payer: BCBS MT POS	$11.83
Rate for Payer: BCBS MT Traditional	$12.45
Rate for Payer: Cash Price	$11.21
Rate for Payer: Cigna Commercial	$11.83
Rate for Payer: Cigna Medicare	$11.21
Rate for Payer: Medicaid All Medicaid	$11.45
Rate for Payer: Medicare All Medicare	$8.71
Rate for Payer: Monida Allegiance	$11.83
Rate for Payer: Monida First Choice Health	$12.08
Rate for Payer: Monida Montana Health Co-op	$11.83
Rate for Payer: Monida PacificSource	$11.83

TUCKS MEDICATED COOLING PADS

Facility

$12.45

Hospital Charge Code	3007354
Hospital Revenue Code	250
Min. Negotiated Rate	$8.71
Max. Negotiated Rate	$12.45
Rate for Payer: Aetna Commercial	$11.83
Rate for Payer: Aetna Medicare	$11.21
Rate for Payer: BCBS MT CHIP	$11.21
Rate for Payer: BCBS MT Closed Plan Network	$11.83
Rate for Payer: BCBS MT HealthLink	$11.21
Rate for Payer: BCBS MT Medicare	$11.21
Rate for Payer: BCBS MT POS	$11.83
Rate for Payer: BCBS MT Traditional	$12.45
Rate for Payer: Cash Price	$11.21
Rate for Payer: Cigna Commercial	$11.83
Rate for Payer: Cigna Medicare	$11.21
Rate for Payer: Medicaid All Medicaid	$11.45
Rate for Payer: Medicare All Medicare	$8.71
Rate for Payer: Monida Allegiance	$11.83
Rate for Payer: Monida First Choice Health	$12.08
Rate for Payer: Monida Montana Health Co-op	$11.83
Rate for Payer: Monida PacificSource	$11.83

TX DISLOC JT W/O ANES W/MANIP CLO

Facility

$642.00

Hospital Charge Code	8126770
Hospital Revenue Code	520
Min. Negotiated Rate	$449.40
Max. Negotiated Rate	$642.00
Rate for Payer: Aetna Commercial	$609.90
Rate for Payer: Aetna Medicare	$577.80
Rate for Payer: BCBS MT CHIP	$577.80
Rate for Payer: BCBS MT Closed Plan Network	$609.90
Rate for Payer: BCBS MT HealthLink	$577.80
Rate for Payer: BCBS MT Medicare	$577.80
Rate for Payer: BCBS MT POS	$609.90
Rate for Payer: BCBS MT Traditional	$642.00
Rate for Payer: Cash Price	$577.80
Rate for Payer: Cigna Commercial	$609.90
Rate for Payer: Cigna Medicare	$577.80
Rate for Payer: Medicaid All Medicaid	$590.64
Rate for Payer: Medicare All Medicare	$449.40
Rate for Payer: Monida Allegiance	$609.90
Rate for Payer: Monida First Choice Health	$622.74
Rate for Payer: Monida Montana Health Co-op	$609.90
Rate for Payer: Monida PacificSource	$609.90

TX DISLOC JT W/O ANES W/MANIP CLO

Facility

$642.00

Hospital Charge Code	8126770
Hospital Revenue Code	520
Min. Negotiated Rate	$449.40
Max. Negotiated Rate	$642.00
Rate for Payer: Aetna Commercial	$609.90
Rate for Payer: Aetna Medicare	$577.80
Rate for Payer: BCBS MT CHIP	$577.80
Rate for Payer: BCBS MT Closed Plan Network	$609.90
Rate for Payer: BCBS MT HealthLink	$577.80
Rate for Payer: BCBS MT Medicare	$577.80
Rate for Payer: BCBS MT POS	$609.90
Rate for Payer: BCBS MT Traditional	$642.00
Rate for Payer: Cash Price	$577.80
Rate for Payer: Cigna Commercial	$609.90
Rate for Payer: Cigna Medicare	$577.80
Rate for Payer: Medicaid All Medicaid	$590.64
Rate for Payer: Medicare All Medicare	$449.40
Rate for Payer: Monida Allegiance	$609.90
Rate for Payer: Monida First Choice Health	$622.74
Rate for Payer: Monida Montana Health Co-op	$609.90
Rate for Payer: Monida PacificSource	$609.90

ULTRA CENTRIFUGE

Facility

$1,016.60

Hospital Charge Code	90197162
Hospital Revenue Code	270
Min. Negotiated Rate	$711.62
Max. Negotiated Rate	$1,016.60
Rate for Payer: Aetna Commercial	$965.77
Rate for Payer: Aetna Medicare	$914.94
Rate for Payer: BCBS MT CHIP	$914.94
Rate for Payer: BCBS MT Closed Plan Network	$965.77
Rate for Payer: BCBS MT HealthLink	$914.94
Rate for Payer: BCBS MT Medicare	$914.94
Rate for Payer: BCBS MT POS	$965.77
Rate for Payer: BCBS MT Traditional	$1,016.60
Rate for Payer: Cash Price	$914.94
Rate for Payer: Cigna Commercial	$965.77
Rate for Payer: Cigna Medicare	$914.94
Rate for Payer: Medicaid All Medicaid	$935.27
Rate for Payer: Medicare All Medicare	$711.62
Rate for Payer: Monida Allegiance	$965.77
Rate for Payer: Monida First Choice Health	$986.10
Rate for Payer: Monida Montana Health Co-op	$965.77
Rate for Payer: Monida PacificSource	$965.77

ULTRA CENTRIFUGE

Facility

$1,016.60

Hospital Charge Code	90197162
Hospital Revenue Code	270
Min. Negotiated Rate	$711.62
Max. Negotiated Rate	$1,016.60
Rate for Payer: Aetna Commercial	$965.77
Rate for Payer: Aetna Medicare	$914.94
Rate for Payer: BCBS MT CHIP	$914.94
Rate for Payer: BCBS MT Closed Plan Network	$965.77
Rate for Payer: BCBS MT HealthLink	$914.94
Rate for Payer: BCBS MT Medicare	$914.94
Rate for Payer: BCBS MT POS	$965.77
Rate for Payer: BCBS MT Traditional	$1,016.60
Rate for Payer: Cash Price	$914.94
Rate for Payer: Cigna Commercial	$965.77
Rate for Payer: Cigna Medicare	$914.94
Rate for Payer: Medicaid All Medicaid	$935.27
Rate for Payer: Medicare All Medicare	$711.62
Rate for Payer: Monida Allegiance	$965.77
Rate for Payer: Monida First Choice Health	$986.10
Rate for Payer: Monida Montana Health Co-op	$965.77
Rate for Payer: Monida PacificSource	$965.77

ULTRASENSITIVE PSA

Facility

$89.00

Service Code	CPT 84153
Hospital Charge Code	4087936
Hospital Revenue Code	301
Min. Negotiated Rate	$62.30
Max. Negotiated Rate	$89.00
Rate for Payer: Aetna Commercial	$84.55
Rate for Payer: Aetna Medicare	$80.10
Rate for Payer: BCBS MT CHIP	$80.10
Rate for Payer: BCBS MT Closed Plan Network	$84.55
Rate for Payer: BCBS MT HealthLink	$80.10
Rate for Payer: BCBS MT Medicare	$80.10
Rate for Payer: BCBS MT POS	$84.55
Rate for Payer: BCBS MT Traditional	$89.00
Rate for Payer: Cash Price	$80.10
Rate for Payer: Cigna Commercial	$84.55
Rate for Payer: Cigna Medicare	$80.10
Rate for Payer: Medicaid All Medicaid	$81.88
Rate for Payer: Medicare All Medicare	$62.30
Rate for Payer: Monida Allegiance	$84.55
Rate for Payer: Monida First Choice Health	$86.33
Rate for Payer: Monida Montana Health Co-op	$84.55
Rate for Payer: Monida PacificSource	$84.55

Know your out-of-pocket cost for care.

All Charges