Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

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

UMECLIDINIUM/VILANTEROL [62.5/25MCG] NF

Facility

$452.00

Hospital Charge Code	3007458
Hospital Revenue Code	250
Min. Negotiated Rate	$316.40
Max. Negotiated Rate	$452.00
Rate for Payer: Aetna Commercial	$429.40
Rate for Payer: Aetna Medicare	$406.80
Rate for Payer: BCBS MT CHIP	$406.80
Rate for Payer: BCBS MT Closed Plan Network	$429.40
Rate for Payer: BCBS MT HealthLink	$406.80
Rate for Payer: BCBS MT Medicare	$406.80
Rate for Payer: BCBS MT POS	$429.40
Rate for Payer: BCBS MT Traditional	$452.00
Rate for Payer: Cash Price	$406.80
Rate for Payer: Cigna Commercial	$429.40
Rate for Payer: Cigna Medicare	$406.80
Rate for Payer: Medicaid All Medicaid	$415.84
Rate for Payer: Medicare All Medicare	$316.40
Rate for Payer: Monida Allegiance	$429.40
Rate for Payer: Monida First Choice Health	$438.44
Rate for Payer: Monida Montana Health Co-op	$429.40
Rate for Payer: Monida PacificSource	$429.40

UMECLIDINIUM/VILANTEROL [62.5/25MCG] NF

Facility

$452.00

Hospital Charge Code	3007458
Hospital Revenue Code	250
Min. Negotiated Rate	$316.40
Max. Negotiated Rate	$452.00
Rate for Payer: Aetna Commercial	$429.40
Rate for Payer: Aetna Medicare	$406.80
Rate for Payer: BCBS MT CHIP	$406.80
Rate for Payer: BCBS MT Closed Plan Network	$429.40
Rate for Payer: BCBS MT HealthLink	$406.80
Rate for Payer: BCBS MT Medicare	$406.80
Rate for Payer: BCBS MT POS	$429.40
Rate for Payer: BCBS MT Traditional	$452.00
Rate for Payer: Cash Price	$406.80
Rate for Payer: Cigna Commercial	$429.40
Rate for Payer: Cigna Medicare	$406.80
Rate for Payer: Medicaid All Medicaid	$415.84
Rate for Payer: Medicare All Medicare	$316.40
Rate for Payer: Monida Allegiance	$429.40
Rate for Payer: Monida First Choice Health	$438.44
Rate for Payer: Monida Montana Health Co-op	$429.40
Rate for Payer: Monida PacificSource	$429.40

UNLISTED MOLECULAR PATHOLOGY

Facility

$1,518.99

Service Code	CPT 81406
Hospital Charge Code	4081479
Hospital Revenue Code	310
Min. Negotiated Rate	$1,063.29
Max. Negotiated Rate	$1,518.99
Rate for Payer: Aetna Commercial	$1,443.04
Rate for Payer: Aetna Medicare	$1,367.09
Rate for Payer: BCBS MT CHIP	$1,367.09
Rate for Payer: BCBS MT Closed Plan Network	$1,443.04
Rate for Payer: BCBS MT HealthLink	$1,367.09
Rate for Payer: BCBS MT Medicare	$1,367.09
Rate for Payer: BCBS MT POS	$1,443.04
Rate for Payer: BCBS MT Traditional	$1,518.99
Rate for Payer: Cash Price	$1,367.09
Rate for Payer: Cigna Commercial	$1,443.04
Rate for Payer: Cigna Medicare	$1,367.09
Rate for Payer: Medicaid All Medicaid	$1,397.47
Rate for Payer: Medicare All Medicare	$1,063.29
Rate for Payer: Monida Allegiance	$1,443.04
Rate for Payer: Monida First Choice Health	$1,473.42
Rate for Payer: Monida Montana Health Co-op	$1,443.04
Rate for Payer: Monida PacificSource	$1,443.04

UNLISTED MOLECULAR PATHOLOGY

Facility

$1,518.99

Service Code	CPT 81406
Hospital Charge Code	4081479
Hospital Revenue Code	310
Min. Negotiated Rate	$1,063.29
Max. Negotiated Rate	$1,518.99
Rate for Payer: Aetna Commercial	$1,443.04
Rate for Payer: Aetna Medicare	$1,367.09
Rate for Payer: BCBS MT CHIP	$1,367.09
Rate for Payer: BCBS MT Closed Plan Network	$1,443.04
Rate for Payer: BCBS MT HealthLink	$1,367.09
Rate for Payer: BCBS MT Medicare	$1,367.09
Rate for Payer: BCBS MT POS	$1,443.04
Rate for Payer: BCBS MT Traditional	$1,518.99
Rate for Payer: Cash Price	$1,367.09
Rate for Payer: Cigna Commercial	$1,443.04
Rate for Payer: Cigna Medicare	$1,367.09
Rate for Payer: Medicaid All Medicaid	$1,397.47
Rate for Payer: Medicare All Medicare	$1,063.29
Rate for Payer: Monida Allegiance	$1,443.04
Rate for Payer: Monida First Choice Health	$1,473.42
Rate for Payer: Monida Montana Health Co-op	$1,443.04
Rate for Payer: Monida PacificSource	$1,443.04

UNLISTED PROC, NERVOUS SYSTEM 64999

Facility

$1,588.00

Service Code	CPT 64999
Hospital Charge Code	1564999
Hospital Revenue Code	761
Min. Negotiated Rate	$1,111.60
Max. Negotiated Rate	$1,588.00
Rate for Payer: Aetna Commercial	$1,508.60
Rate for Payer: Aetna Medicare	$1,429.20
Rate for Payer: BCBS MT CHIP	$1,429.20
Rate for Payer: BCBS MT Closed Plan Network	$1,508.60
Rate for Payer: BCBS MT HealthLink	$1,429.20
Rate for Payer: BCBS MT Medicare	$1,429.20
Rate for Payer: BCBS MT POS	$1,508.60
Rate for Payer: BCBS MT Traditional	$1,588.00
Rate for Payer: Cash Price	$1,429.20
Rate for Payer: Cigna Commercial	$1,508.60
Rate for Payer: Cigna Medicare	$1,429.20
Rate for Payer: Medicaid All Medicaid	$1,460.96
Rate for Payer: Medicare All Medicare	$1,111.60
Rate for Payer: Monida Allegiance	$1,508.60
Rate for Payer: Monida First Choice Health	$1,540.36
Rate for Payer: Monida Montana Health Co-op	$1,508.60
Rate for Payer: Monida PacificSource	$1,508.60

UNLISTED PROC, NERVOUS SYSTEM 64999

Facility

$1,588.00

Service Code	CPT 64999
Hospital Charge Code	1564999
Hospital Revenue Code	761
Min. Negotiated Rate	$1,111.60
Max. Negotiated Rate	$1,588.00
Rate for Payer: Aetna Commercial	$1,508.60
Rate for Payer: Aetna Medicare	$1,429.20
Rate for Payer: BCBS MT CHIP	$1,429.20
Rate for Payer: BCBS MT Closed Plan Network	$1,508.60
Rate for Payer: BCBS MT HealthLink	$1,429.20
Rate for Payer: BCBS MT Medicare	$1,429.20
Rate for Payer: BCBS MT POS	$1,508.60
Rate for Payer: BCBS MT Traditional	$1,588.00
Rate for Payer: Cash Price	$1,429.20
Rate for Payer: Cigna Commercial	$1,508.60
Rate for Payer: Cigna Medicare	$1,429.20
Rate for Payer: Medicaid All Medicaid	$1,460.96
Rate for Payer: Medicare All Medicare	$1,111.60
Rate for Payer: Monida Allegiance	$1,508.60
Rate for Payer: Monida First Choice Health	$1,540.36
Rate for Payer: Monida Montana Health Co-op	$1,508.60
Rate for Payer: Monida PacificSource	$1,508.60

UNLISTED PSYCIATRIC PRO/THERAPY

Facility

$240.00

Service Code	CPT 90899
Hospital Charge Code	8090899
Hospital Revenue Code	900
Min. Negotiated Rate	$168.00
Max. Negotiated Rate	$240.00
Rate for Payer: Aetna Commercial	$228.00
Rate for Payer: Aetna Medicare	$216.00
Rate for Payer: BCBS MT CHIP	$216.00
Rate for Payer: BCBS MT Closed Plan Network	$228.00
Rate for Payer: BCBS MT HealthLink	$216.00
Rate for Payer: BCBS MT Medicare	$216.00
Rate for Payer: BCBS MT POS	$228.00
Rate for Payer: BCBS MT Traditional	$240.00
Rate for Payer: Cash Price	$216.00
Rate for Payer: Cigna Commercial	$228.00
Rate for Payer: Cigna Medicare	$216.00
Rate for Payer: Medicaid All Medicaid	$220.80
Rate for Payer: Medicare All Medicare	$168.00
Rate for Payer: Monida Allegiance	$228.00
Rate for Payer: Monida First Choice Health	$232.80
Rate for Payer: Monida Montana Health Co-op	$228.00
Rate for Payer: Monida PacificSource	$228.00

UNLISTED PSYCIATRIC PRO/THERAPY

Facility

$240.00

Service Code	CPT 90899
Hospital Charge Code	8090899
Hospital Revenue Code	900
Min. Negotiated Rate	$168.00
Max. Negotiated Rate	$240.00
Rate for Payer: Aetna Commercial	$228.00
Rate for Payer: Aetna Medicare	$216.00
Rate for Payer: BCBS MT CHIP	$216.00
Rate for Payer: BCBS MT Closed Plan Network	$228.00
Rate for Payer: BCBS MT HealthLink	$216.00
Rate for Payer: BCBS MT Medicare	$216.00
Rate for Payer: BCBS MT POS	$228.00
Rate for Payer: BCBS MT Traditional	$240.00
Rate for Payer: Cash Price	$216.00
Rate for Payer: Cigna Commercial	$228.00
Rate for Payer: Cigna Medicare	$216.00
Rate for Payer: Medicaid All Medicaid	$220.80
Rate for Payer: Medicare All Medicare	$168.00
Rate for Payer: Monida Allegiance	$228.00
Rate for Payer: Monida First Choice Health	$232.80
Rate for Payer: Monida Montana Health Co-op	$228.00
Rate for Payer: Monida PacificSource	$228.00

UNLISTED VACCINE/TOXOID

Facility

$36.00

Service Code	CPT 90749
Hospital Charge Code	8090749
Hospital Revenue Code	521
Min. Negotiated Rate	$25.20
Max. Negotiated Rate	$36.00
Rate for Payer: Aetna Commercial	$34.20
Rate for Payer: Aetna Medicare	$32.40
Rate for Payer: BCBS MT CHIP	$32.40
Rate for Payer: BCBS MT Closed Plan Network	$34.20
Rate for Payer: BCBS MT HealthLink	$32.40
Rate for Payer: BCBS MT Medicare	$32.40
Rate for Payer: BCBS MT POS	$34.20
Rate for Payer: BCBS MT Traditional	$36.00
Rate for Payer: Cash Price	$32.40
Rate for Payer: Cigna Commercial	$34.20
Rate for Payer: Cigna Medicare	$32.40
Rate for Payer: Medicaid All Medicaid	$33.12
Rate for Payer: Medicare All Medicare	$25.20
Rate for Payer: Monida Allegiance	$34.20
Rate for Payer: Monida First Choice Health	$34.92
Rate for Payer: Monida Montana Health Co-op	$34.20
Rate for Payer: Monida PacificSource	$34.20

UNLISTED VACCINE/TOXOID

Facility

$36.00

Service Code	CPT 90749
Hospital Charge Code	8090749
Hospital Revenue Code	521
Min. Negotiated Rate	$25.20
Max. Negotiated Rate	$36.00
Rate for Payer: Aetna Commercial	$34.20
Rate for Payer: Aetna Medicare	$32.40
Rate for Payer: BCBS MT CHIP	$32.40
Rate for Payer: BCBS MT Closed Plan Network	$34.20
Rate for Payer: BCBS MT HealthLink	$32.40
Rate for Payer: BCBS MT Medicare	$32.40
Rate for Payer: BCBS MT POS	$34.20
Rate for Payer: BCBS MT Traditional	$36.00
Rate for Payer: Cash Price	$32.40
Rate for Payer: Cigna Commercial	$34.20
Rate for Payer: Cigna Medicare	$32.40
Rate for Payer: Medicaid All Medicaid	$33.12
Rate for Payer: Medicare All Medicare	$25.20
Rate for Payer: Monida Allegiance	$34.20
Rate for Payer: Monida First Choice Health	$34.92
Rate for Payer: Monida Montana Health Co-op	$34.20
Rate for Payer: Monida PacificSource	$34.20

UNNA BOOT

Facility

$286.00

Service Code	CPT 29580
Hospital Charge Code	8029580
Hospital Revenue Code	521
Min. Negotiated Rate	$200.20
Max. Negotiated Rate	$286.00
Rate for Payer: Aetna Commercial	$271.70
Rate for Payer: Aetna Medicare	$257.40
Rate for Payer: BCBS MT CHIP	$257.40
Rate for Payer: BCBS MT Closed Plan Network	$271.70
Rate for Payer: BCBS MT HealthLink	$257.40
Rate for Payer: BCBS MT Medicare	$257.40
Rate for Payer: BCBS MT POS	$271.70
Rate for Payer: BCBS MT Traditional	$286.00
Rate for Payer: Cash Price	$257.40
Rate for Payer: Cigna Commercial	$271.70
Rate for Payer: Cigna Medicare	$257.40
Rate for Payer: Medicaid All Medicaid	$263.12
Rate for Payer: Medicare All Medicare	$200.20
Rate for Payer: Monida Allegiance	$271.70
Rate for Payer: Monida First Choice Health	$277.42
Rate for Payer: Monida Montana Health Co-op	$271.70
Rate for Payer: Monida PacificSource	$271.70

UNNA BOOT

Facility

$286.00

Service Code	CPT 29580
Hospital Charge Code	8029580
Hospital Revenue Code	521
Min. Negotiated Rate	$200.20
Max. Negotiated Rate	$286.00
Rate for Payer: Aetna Commercial	$271.70
Rate for Payer: Aetna Medicare	$257.40
Rate for Payer: BCBS MT CHIP	$257.40
Rate for Payer: BCBS MT Closed Plan Network	$271.70
Rate for Payer: BCBS MT HealthLink	$257.40
Rate for Payer: BCBS MT Medicare	$257.40
Rate for Payer: BCBS MT POS	$271.70
Rate for Payer: BCBS MT Traditional	$286.00
Rate for Payer: Cash Price	$257.40
Rate for Payer: Cigna Commercial	$271.70
Rate for Payer: Cigna Medicare	$257.40
Rate for Payer: Medicaid All Medicaid	$263.12
Rate for Payer: Medicare All Medicare	$200.20
Rate for Payer: Monida Allegiance	$271.70
Rate for Payer: Monida First Choice Health	$277.42
Rate for Payer: Monida Montana Health Co-op	$271.70
Rate for Payer: Monida PacificSource	$271.70

UNNA BOOT BANDAGE 3''

Facility

$57.00

Hospital Charge Code	80030445
Hospital Revenue Code	270
Min. Negotiated Rate	$39.90
Max. Negotiated Rate	$57.00
Rate for Payer: Aetna Commercial	$54.15
Rate for Payer: Aetna Medicare	$51.30
Rate for Payer: BCBS MT CHIP	$51.30
Rate for Payer: BCBS MT Closed Plan Network	$54.15
Rate for Payer: BCBS MT HealthLink	$51.30
Rate for Payer: BCBS MT Medicare	$51.30
Rate for Payer: BCBS MT POS	$54.15
Rate for Payer: BCBS MT Traditional	$57.00
Rate for Payer: Cash Price	$51.30
Rate for Payer: Cigna Commercial	$54.15
Rate for Payer: Cigna Medicare	$51.30
Rate for Payer: Medicaid All Medicaid	$52.44
Rate for Payer: Medicare All Medicare	$39.90
Rate for Payer: Monida Allegiance	$54.15
Rate for Payer: Monida First Choice Health	$55.29
Rate for Payer: Monida Montana Health Co-op	$54.15
Rate for Payer: Monida PacificSource	$54.15

UNNA BOOT BANDAGE 3''

Facility

$57.00

Hospital Charge Code	80030445
Hospital Revenue Code	270
Min. Negotiated Rate	$39.90
Max. Negotiated Rate	$57.00
Rate for Payer: Aetna Commercial	$54.15
Rate for Payer: Aetna Medicare	$51.30
Rate for Payer: BCBS MT CHIP	$51.30
Rate for Payer: BCBS MT Closed Plan Network	$54.15
Rate for Payer: BCBS MT HealthLink	$51.30
Rate for Payer: BCBS MT Medicare	$51.30
Rate for Payer: BCBS MT POS	$54.15
Rate for Payer: BCBS MT Traditional	$57.00
Rate for Payer: Cash Price	$51.30
Rate for Payer: Cigna Commercial	$54.15
Rate for Payer: Cigna Medicare	$51.30
Rate for Payer: Medicaid All Medicaid	$52.44
Rate for Payer: Medicare All Medicare	$39.90
Rate for Payer: Monida Allegiance	$54.15
Rate for Payer: Monida First Choice Health	$55.29
Rate for Payer: Monida Montana Health Co-op	$54.15
Rate for Payer: Monida PacificSource	$54.15

UPPER RESPIRATORY CULTURE (008342)

Facility

$64.00

Service Code	CPT 87070
Hospital Charge Code	4070702
Hospital Revenue Code	306
Min. Negotiated Rate	$44.80
Max. Negotiated Rate	$64.00
Rate for Payer: Aetna Commercial	$60.80
Rate for Payer: Aetna Medicare	$57.60
Rate for Payer: BCBS MT CHIP	$57.60
Rate for Payer: BCBS MT Closed Plan Network	$60.80
Rate for Payer: BCBS MT HealthLink	$57.60
Rate for Payer: BCBS MT Medicare	$57.60
Rate for Payer: BCBS MT POS	$60.80
Rate for Payer: BCBS MT Traditional	$64.00
Rate for Payer: Cash Price	$57.60
Rate for Payer: Cigna Commercial	$60.80
Rate for Payer: Cigna Medicare	$57.60
Rate for Payer: Medicaid All Medicaid	$58.88
Rate for Payer: Medicare All Medicare	$44.80
Rate for Payer: Monida Allegiance	$60.80
Rate for Payer: Monida First Choice Health	$62.08
Rate for Payer: Monida Montana Health Co-op	$60.80
Rate for Payer: Monida PacificSource	$60.80

UPPER RESPIRATORY CULTURE (008342)

Facility

$64.00

Service Code	CPT 87070
Hospital Charge Code	4070702
Hospital Revenue Code	306
Min. Negotiated Rate	$44.80
Max. Negotiated Rate	$64.00
Rate for Payer: Aetna Commercial	$60.80
Rate for Payer: Aetna Medicare	$57.60
Rate for Payer: BCBS MT CHIP	$57.60
Rate for Payer: BCBS MT Closed Plan Network	$60.80
Rate for Payer: BCBS MT HealthLink	$57.60
Rate for Payer: BCBS MT Medicare	$57.60
Rate for Payer: BCBS MT POS	$60.80
Rate for Payer: BCBS MT Traditional	$64.00
Rate for Payer: Cash Price	$57.60
Rate for Payer: Cigna Commercial	$60.80
Rate for Payer: Cigna Medicare	$57.60
Rate for Payer: Medicaid All Medicaid	$58.88
Rate for Payer: Medicare All Medicare	$44.80
Rate for Payer: Monida Allegiance	$60.80
Rate for Payer: Monida First Choice Health	$62.08
Rate for Payer: Monida Montana Health Co-op	$60.80
Rate for Payer: Monida PacificSource	$60.80

UREAPLASMA AND MYCOPLASMA NAAT

Facility

$120.00

Service Code	CPT 87798
Hospital Charge Code	4088077
Hospital Revenue Code	302
Min. Negotiated Rate	$84.00
Max. Negotiated Rate	$120.00
Rate for Payer: Aetna Commercial	$114.00
Rate for Payer: Aetna Medicare	$108.00
Rate for Payer: BCBS MT CHIP	$108.00
Rate for Payer: BCBS MT Closed Plan Network	$114.00
Rate for Payer: BCBS MT HealthLink	$108.00
Rate for Payer: BCBS MT Medicare	$108.00
Rate for Payer: BCBS MT POS	$114.00
Rate for Payer: BCBS MT Traditional	$120.00
Rate for Payer: Cash Price	$108.00
Rate for Payer: Cigna Commercial	$114.00
Rate for Payer: Cigna Medicare	$108.00
Rate for Payer: Medicaid All Medicaid	$110.40
Rate for Payer: Medicare All Medicare	$84.00
Rate for Payer: Monida Allegiance	$114.00
Rate for Payer: Monida First Choice Health	$116.40
Rate for Payer: Monida Montana Health Co-op	$114.00
Rate for Payer: Monida PacificSource	$114.00

UREAPLASMA AND MYCOPLASMA NAAT

Facility

$120.00

Service Code	CPT 87798
Hospital Charge Code	4088077
Hospital Revenue Code	302
Min. Negotiated Rate	$84.00
Max. Negotiated Rate	$120.00
Rate for Payer: Aetna Commercial	$114.00
Rate for Payer: Aetna Medicare	$108.00
Rate for Payer: BCBS MT CHIP	$108.00
Rate for Payer: BCBS MT Closed Plan Network	$114.00
Rate for Payer: BCBS MT HealthLink	$108.00
Rate for Payer: BCBS MT Medicare	$108.00
Rate for Payer: BCBS MT POS	$114.00
Rate for Payer: BCBS MT Traditional	$120.00
Rate for Payer: Cash Price	$108.00
Rate for Payer: Cigna Commercial	$114.00
Rate for Payer: Cigna Medicare	$108.00
Rate for Payer: Medicaid All Medicaid	$110.40
Rate for Payer: Medicare All Medicare	$84.00
Rate for Payer: Monida Allegiance	$114.00
Rate for Payer: Monida First Choice Health	$116.40
Rate for Payer: Monida Montana Health Co-op	$114.00
Rate for Payer: Monida PacificSource	$114.00

URETHRAL CATHETER TRAY ( STRAIGHT CATH)

Facility

$27.00

Hospital Charge Code	80030068
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

URETHRAL CATHETER TRAY ( STRAIGHT CATH)

Facility

$27.00

Hospital Charge Code	80030068
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

URETHRAL CATH KIT

Facility

$53.00

Hospital Charge Code	80030430
Hospital Revenue Code	270
Min. Negotiated Rate	$37.10
Max. Negotiated Rate	$53.00
Rate for Payer: Aetna Commercial	$50.35
Rate for Payer: Aetna Medicare	$47.70
Rate for Payer: BCBS MT CHIP	$47.70
Rate for Payer: BCBS MT Closed Plan Network	$50.35
Rate for Payer: BCBS MT HealthLink	$47.70
Rate for Payer: BCBS MT Medicare	$47.70
Rate for Payer: BCBS MT POS	$50.35
Rate for Payer: BCBS MT Traditional	$53.00
Rate for Payer: Cash Price	$47.70
Rate for Payer: Cigna Commercial	$50.35
Rate for Payer: Cigna Medicare	$47.70
Rate for Payer: Medicaid All Medicaid	$48.76
Rate for Payer: Medicare All Medicare	$37.10
Rate for Payer: Monida Allegiance	$50.35
Rate for Payer: Monida First Choice Health	$51.41
Rate for Payer: Monida Montana Health Co-op	$50.35
Rate for Payer: Monida PacificSource	$50.35

URETHRAL CATH KIT

Facility

$53.00

Hospital Charge Code	80030430
Hospital Revenue Code	270
Min. Negotiated Rate	$37.10
Max. Negotiated Rate	$53.00
Rate for Payer: Aetna Commercial	$50.35
Rate for Payer: Aetna Medicare	$47.70
Rate for Payer: BCBS MT CHIP	$47.70
Rate for Payer: BCBS MT Closed Plan Network	$50.35
Rate for Payer: BCBS MT HealthLink	$47.70
Rate for Payer: BCBS MT Medicare	$47.70
Rate for Payer: BCBS MT POS	$50.35
Rate for Payer: BCBS MT Traditional	$53.00
Rate for Payer: Cash Price	$47.70
Rate for Payer: Cigna Commercial	$50.35
Rate for Payer: Cigna Medicare	$47.70
Rate for Payer: Medicaid All Medicaid	$48.76
Rate for Payer: Medicare All Medicare	$37.10
Rate for Payer: Monida Allegiance	$50.35
Rate for Payer: Monida First Choice Health	$51.41
Rate for Payer: Monida Montana Health Co-op	$50.35
Rate for Payer: Monida PacificSource	$50.35

URIC ACID

Facility

$68.00

Service Code	CPT 84550
Hospital Charge Code	4084550
Hospital Revenue Code	301
Min. Negotiated Rate	$47.60
Max. Negotiated Rate	$68.00
Rate for Payer: Aetna Commercial	$64.60
Rate for Payer: Aetna Medicare	$61.20
Rate for Payer: BCBS MT CHIP	$61.20
Rate for Payer: BCBS MT Closed Plan Network	$64.60
Rate for Payer: BCBS MT HealthLink	$61.20
Rate for Payer: BCBS MT Medicare	$61.20
Rate for Payer: BCBS MT POS	$64.60
Rate for Payer: BCBS MT Traditional	$68.00
Rate for Payer: Cash Price	$61.20
Rate for Payer: Cigna Commercial	$64.60
Rate for Payer: Cigna Medicare	$61.20
Rate for Payer: Medicaid All Medicaid	$62.56
Rate for Payer: Medicare All Medicare	$47.60
Rate for Payer: Monida Allegiance	$64.60
Rate for Payer: Monida First Choice Health	$65.96
Rate for Payer: Monida Montana Health Co-op	$64.60
Rate for Payer: Monida PacificSource	$64.60

URIC ACID

Facility

$68.00

Service Code	CPT 84550
Hospital Charge Code	4084550
Hospital Revenue Code	301
Min. Negotiated Rate	$47.60
Max. Negotiated Rate	$68.00
Rate for Payer: Aetna Commercial	$64.60
Rate for Payer: Aetna Medicare	$61.20
Rate for Payer: BCBS MT CHIP	$61.20
Rate for Payer: BCBS MT Closed Plan Network	$64.60
Rate for Payer: BCBS MT HealthLink	$61.20
Rate for Payer: BCBS MT Medicare	$61.20
Rate for Payer: BCBS MT POS	$64.60
Rate for Payer: BCBS MT Traditional	$68.00
Rate for Payer: Cash Price	$61.20
Rate for Payer: Cigna Commercial	$64.60
Rate for Payer: Cigna Medicare	$61.20
Rate for Payer: Medicaid All Medicaid	$62.56
Rate for Payer: Medicare All Medicare	$47.60
Rate for Payer: Monida Allegiance	$64.60
Rate for Payer: Monida First Choice Health	$65.96
Rate for Payer: Monida Montana Health Co-op	$64.60
Rate for Payer: Monida PacificSource	$64.60

Know your out-of-pocket cost for care.

All Charges