Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

CHarge Only (DICYCLOMINE HCL) 10mg/5ml

Facility

$5.00

Service Code	HCPCS J3490
Hospital Charge Code	3000084
Hospital Revenue Code	250
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

Charge Only (LIDOCAINE VISCOUS 2%)

Facility

$5.00

Service Code	HCPCS J3490
Hospital Charge Code	3000085
Hospital Revenue Code	250
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

Charge Only (LIDOCAINE VISCOUS 2%)

Facility

$5.00

Service Code	HCPCS J3490
Hospital Charge Code	3000085
Hospital Revenue Code	250
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

CHART RECORDER REFRIGERATOR

Facility

$208.20

Hospital Charge Code	90196616
Hospital Revenue Code	270
Min. Negotiated Rate	$145.74
Max. Negotiated Rate	$208.20
Rate for Payer: Aetna Commercial	$197.79
Rate for Payer: Aetna Medicare	$187.38
Rate for Payer: BCBS MT CHIP	$187.38
Rate for Payer: BCBS MT Closed Plan Network	$197.79
Rate for Payer: BCBS MT HealthLink	$187.38
Rate for Payer: BCBS MT Medicare	$187.38
Rate for Payer: BCBS MT POS	$197.79
Rate for Payer: BCBS MT Traditional	$208.20
Rate for Payer: Cash Price	$187.38
Rate for Payer: Cigna Commercial	$197.79
Rate for Payer: Cigna Medicare	$187.38
Rate for Payer: Medicaid All Medicaid	$191.54
Rate for Payer: Medicare All Medicare	$145.74
Rate for Payer: Monida Allegiance	$197.79
Rate for Payer: Monida First Choice Health	$201.95
Rate for Payer: Monida Montana Health Co-op	$197.79
Rate for Payer: Monida PacificSource	$197.79

CHART RECORDER REFRIGERATOR

Facility

$208.20

Hospital Charge Code	90196616
Hospital Revenue Code	270
Min. Negotiated Rate	$145.74
Max. Negotiated Rate	$208.20
Rate for Payer: Aetna Commercial	$197.79
Rate for Payer: Aetna Medicare	$187.38
Rate for Payer: BCBS MT CHIP	$187.38
Rate for Payer: BCBS MT Closed Plan Network	$197.79
Rate for Payer: BCBS MT HealthLink	$187.38
Rate for Payer: BCBS MT Medicare	$187.38
Rate for Payer: BCBS MT POS	$197.79
Rate for Payer: BCBS MT Traditional	$208.20
Rate for Payer: Cash Price	$187.38
Rate for Payer: Cigna Commercial	$197.79
Rate for Payer: Cigna Medicare	$187.38
Rate for Payer: Medicaid All Medicaid	$191.54
Rate for Payer: Medicare All Medicare	$145.74
Rate for Payer: Monida Allegiance	$197.79
Rate for Payer: Monida First Choice Health	$201.95
Rate for Payer: Monida Montana Health Co-op	$197.79
Rate for Payer: Monida PacificSource	$197.79

CHEM I CALIBRATOR DC18C 2 X

Facility

$26.43

Hospital Charge Code	90195222
Hospital Revenue Code	270
Min. Negotiated Rate	$18.50
Max. Negotiated Rate	$26.43
Rate for Payer: Aetna Commercial	$25.11
Rate for Payer: Aetna Medicare	$23.79
Rate for Payer: BCBS MT CHIP	$23.79
Rate for Payer: BCBS MT Closed Plan Network	$25.11
Rate for Payer: BCBS MT HealthLink	$23.79
Rate for Payer: BCBS MT Medicare	$23.79
Rate for Payer: BCBS MT POS	$25.11
Rate for Payer: BCBS MT Traditional	$26.43
Rate for Payer: Cash Price	$23.79
Rate for Payer: Cigna Commercial	$25.11
Rate for Payer: Cigna Medicare	$23.79
Rate for Payer: Medicaid All Medicaid	$24.32
Rate for Payer: Medicare All Medicare	$18.50
Rate for Payer: Monida Allegiance	$25.11
Rate for Payer: Monida First Choice Health	$25.64
Rate for Payer: Monida Montana Health Co-op	$25.11
Rate for Payer: Monida PacificSource	$25.11

CHEM I CALIBRATOR DC18C 2 X

Facility

$26.43

Hospital Charge Code	90195222
Hospital Revenue Code	270
Min. Negotiated Rate	$18.50
Max. Negotiated Rate	$26.43
Rate for Payer: Aetna Commercial	$25.11
Rate for Payer: Aetna Medicare	$23.79
Rate for Payer: BCBS MT CHIP	$23.79
Rate for Payer: BCBS MT Closed Plan Network	$25.11
Rate for Payer: BCBS MT HealthLink	$23.79
Rate for Payer: BCBS MT Medicare	$23.79
Rate for Payer: BCBS MT POS	$25.11
Rate for Payer: BCBS MT Traditional	$26.43
Rate for Payer: Cash Price	$23.79
Rate for Payer: Cigna Commercial	$25.11
Rate for Payer: Cigna Medicare	$23.79
Rate for Payer: Medicaid All Medicaid	$24.32
Rate for Payer: Medicare All Medicare	$18.50
Rate for Payer: Monida Allegiance	$25.11
Rate for Payer: Monida First Choice Health	$25.64
Rate for Payer: Monida Montana Health Co-op	$25.11
Rate for Payer: Monida PacificSource	$25.11

CHEM II CALIBRATOR DC20 2 X

Facility

$30.43

Hospital Charge Code	90195052
Hospital Revenue Code	270
Min. Negotiated Rate	$21.30
Max. Negotiated Rate	$30.43
Rate for Payer: Aetna Commercial	$28.91
Rate for Payer: Aetna Medicare	$27.39
Rate for Payer: BCBS MT CHIP	$27.39
Rate for Payer: BCBS MT Closed Plan Network	$28.91
Rate for Payer: BCBS MT HealthLink	$27.39
Rate for Payer: BCBS MT Medicare	$27.39
Rate for Payer: BCBS MT POS	$28.91
Rate for Payer: BCBS MT Traditional	$30.43
Rate for Payer: Cash Price	$27.39
Rate for Payer: Cigna Commercial	$28.91
Rate for Payer: Cigna Medicare	$27.39
Rate for Payer: Medicaid All Medicaid	$28.00
Rate for Payer: Medicare All Medicare	$21.30
Rate for Payer: Monida Allegiance	$28.91
Rate for Payer: Monida First Choice Health	$29.52
Rate for Payer: Monida Montana Health Co-op	$28.91
Rate for Payer: Monida PacificSource	$28.91

CHEM II CALIBRATOR DC20 2 X

Facility

$30.43

Hospital Charge Code	90195052
Hospital Revenue Code	270
Min. Negotiated Rate	$21.30
Max. Negotiated Rate	$30.43
Rate for Payer: Aetna Commercial	$28.91
Rate for Payer: Aetna Medicare	$27.39
Rate for Payer: BCBS MT CHIP	$27.39
Rate for Payer: BCBS MT Closed Plan Network	$28.91
Rate for Payer: BCBS MT HealthLink	$27.39
Rate for Payer: BCBS MT Medicare	$27.39
Rate for Payer: BCBS MT POS	$28.91
Rate for Payer: BCBS MT Traditional	$30.43
Rate for Payer: Cash Price	$27.39
Rate for Payer: Cigna Commercial	$28.91
Rate for Payer: Cigna Medicare	$27.39
Rate for Payer: Medicaid All Medicaid	$28.00
Rate for Payer: Medicare All Medicare	$21.30
Rate for Payer: Monida Allegiance	$28.91
Rate for Payer: Monida First Choice Health	$29.52
Rate for Payer: Monida Montana Health Co-op	$28.91
Rate for Payer: Monida PacificSource	$28.91

CHEMISTRY WASH SOLUTION RD701

Facility

$16.52

Hospital Charge Code	90195224
Hospital Revenue Code	270
Min. Negotiated Rate	$11.56
Max. Negotiated Rate	$16.52
Rate for Payer: Aetna Commercial	$15.69
Rate for Payer: Aetna Medicare	$14.87
Rate for Payer: BCBS MT CHIP	$14.87
Rate for Payer: BCBS MT Closed Plan Network	$15.69
Rate for Payer: BCBS MT HealthLink	$14.87
Rate for Payer: BCBS MT Medicare	$14.87
Rate for Payer: BCBS MT POS	$15.69
Rate for Payer: BCBS MT Traditional	$16.52
Rate for Payer: Cash Price	$14.87
Rate for Payer: Cigna Commercial	$15.69
Rate for Payer: Cigna Medicare	$14.87
Rate for Payer: Medicaid All Medicaid	$15.20
Rate for Payer: Medicare All Medicare	$11.56
Rate for Payer: Monida Allegiance	$15.69
Rate for Payer: Monida First Choice Health	$16.02
Rate for Payer: Monida Montana Health Co-op	$15.69
Rate for Payer: Monida PacificSource	$15.69

CHEMISTRY WASH SOLUTION RD701

Facility

$16.52

Hospital Charge Code	90195224
Hospital Revenue Code	270
Min. Negotiated Rate	$11.56
Max. Negotiated Rate	$16.52
Rate for Payer: Aetna Commercial	$15.69
Rate for Payer: Aetna Medicare	$14.87
Rate for Payer: BCBS MT CHIP	$14.87
Rate for Payer: BCBS MT Closed Plan Network	$15.69
Rate for Payer: BCBS MT HealthLink	$14.87
Rate for Payer: BCBS MT Medicare	$14.87
Rate for Payer: BCBS MT POS	$15.69
Rate for Payer: BCBS MT Traditional	$16.52
Rate for Payer: Cash Price	$14.87
Rate for Payer: Cigna Commercial	$15.69
Rate for Payer: Cigna Medicare	$14.87
Rate for Payer: Medicaid All Medicaid	$15.20
Rate for Payer: Medicare All Medicare	$11.56
Rate for Payer: Monida Allegiance	$15.69
Rate for Payer: Monida First Choice Health	$16.02
Rate for Payer: Monida Montana Health Co-op	$15.69
Rate for Payer: Monida PacificSource	$15.69

CHEMOTX ADMN SUBQ/IM HORMONAL ANTI-NEO

Facility

$268.00

Service Code	CPT 96402
Hospital Charge Code	596402
Hospital Revenue Code	280
Min. Negotiated Rate	$187.60
Max. Negotiated Rate	$268.00
Rate for Payer: Aetna Commercial	$254.60
Rate for Payer: Aetna Medicare	$241.20
Rate for Payer: BCBS MT CHIP	$241.20
Rate for Payer: BCBS MT Closed Plan Network	$254.60
Rate for Payer: BCBS MT HealthLink	$241.20
Rate for Payer: BCBS MT Medicare	$241.20
Rate for Payer: BCBS MT POS	$254.60
Rate for Payer: BCBS MT Traditional	$268.00
Rate for Payer: Cash Price	$241.20
Rate for Payer: Cigna Commercial	$254.60
Rate for Payer: Cigna Medicare	$241.20
Rate for Payer: Medicaid All Medicaid	$246.56
Rate for Payer: Medicare All Medicare	$187.60
Rate for Payer: Monida Allegiance	$254.60
Rate for Payer: Monida First Choice Health	$259.96
Rate for Payer: Monida Montana Health Co-op	$254.60
Rate for Payer: Monida PacificSource	$254.60

CHEMOTX ADMN SUBQ/IM HORMONAL ANTI-NEO

Facility

$268.00

Service Code	CPT 96402
Hospital Charge Code	596402
Hospital Revenue Code	280
Min. Negotiated Rate	$187.60
Max. Negotiated Rate	$268.00
Rate for Payer: Aetna Commercial	$254.60
Rate for Payer: Aetna Medicare	$241.20
Rate for Payer: BCBS MT CHIP	$241.20
Rate for Payer: BCBS MT Closed Plan Network	$254.60
Rate for Payer: BCBS MT HealthLink	$241.20
Rate for Payer: BCBS MT Medicare	$241.20
Rate for Payer: BCBS MT POS	$254.60
Rate for Payer: BCBS MT Traditional	$268.00
Rate for Payer: Cash Price	$241.20
Rate for Payer: Cigna Commercial	$254.60
Rate for Payer: Cigna Medicare	$241.20
Rate for Payer: Medicaid All Medicaid	$246.56
Rate for Payer: Medicare All Medicare	$187.60
Rate for Payer: Monida Allegiance	$254.60
Rate for Payer: Monida First Choice Health	$259.96
Rate for Payer: Monida Montana Health Co-op	$254.60
Rate for Payer: Monida PacificSource	$254.60

CHEMOTX ADMN SUBQ/IM NON-HORMONAL ANTI-N

Facility

$330.00

Service Code	CPT 96401
Hospital Charge Code	596401
Hospital Revenue Code	280
Min. Negotiated Rate	$231.00
Max. Negotiated Rate	$330.00
Rate for Payer: Aetna Commercial	$313.50
Rate for Payer: Aetna Medicare	$297.00
Rate for Payer: BCBS MT CHIP	$297.00
Rate for Payer: BCBS MT Closed Plan Network	$313.50
Rate for Payer: BCBS MT HealthLink	$297.00
Rate for Payer: BCBS MT Medicare	$297.00
Rate for Payer: BCBS MT POS	$313.50
Rate for Payer: BCBS MT Traditional	$330.00
Rate for Payer: Cash Price	$297.00
Rate for Payer: Cigna Commercial	$313.50
Rate for Payer: Cigna Medicare	$297.00
Rate for Payer: Medicaid All Medicaid	$303.60
Rate for Payer: Medicare All Medicare	$231.00
Rate for Payer: Monida Allegiance	$313.50
Rate for Payer: Monida First Choice Health	$320.10
Rate for Payer: Monida Montana Health Co-op	$313.50
Rate for Payer: Monida PacificSource	$313.50

CHEMOTX ADMN SUBQ/IM NON-HORMONAL ANTI-N

Facility

$330.00

Service Code	CPT 96401
Hospital Charge Code	596401
Hospital Revenue Code	280
Min. Negotiated Rate	$231.00
Max. Negotiated Rate	$330.00
Rate for Payer: Aetna Commercial	$313.50
Rate for Payer: Aetna Medicare	$297.00
Rate for Payer: BCBS MT CHIP	$297.00
Rate for Payer: BCBS MT Closed Plan Network	$313.50
Rate for Payer: BCBS MT HealthLink	$297.00
Rate for Payer: BCBS MT Medicare	$297.00
Rate for Payer: BCBS MT POS	$313.50
Rate for Payer: BCBS MT Traditional	$330.00
Rate for Payer: Cash Price	$297.00
Rate for Payer: Cigna Commercial	$313.50
Rate for Payer: Cigna Medicare	$297.00
Rate for Payer: Medicaid All Medicaid	$303.60
Rate for Payer: Medicare All Medicare	$231.00
Rate for Payer: Monida Allegiance	$313.50
Rate for Payer: Monida First Choice Health	$320.10
Rate for Payer: Monida Montana Health Co-op	$313.50
Rate for Payer: Monida PacificSource	$313.50

CHEST SEAL

Facility

$28.00

Hospital Charge Code	80040209
Hospital Revenue Code	270
Min. Negotiated Rate	$19.60
Max. Negotiated Rate	$28.00
Rate for Payer: Aetna Commercial	$26.60
Rate for Payer: Aetna Medicare	$25.20
Rate for Payer: BCBS MT CHIP	$25.20
Rate for Payer: BCBS MT Closed Plan Network	$26.60
Rate for Payer: BCBS MT HealthLink	$25.20
Rate for Payer: BCBS MT Medicare	$25.20
Rate for Payer: BCBS MT POS	$26.60
Rate for Payer: BCBS MT Traditional	$28.00
Rate for Payer: Cash Price	$25.20
Rate for Payer: Cigna Commercial	$26.60
Rate for Payer: Cigna Medicare	$25.20
Rate for Payer: Medicaid All Medicaid	$25.76
Rate for Payer: Medicare All Medicare	$19.60
Rate for Payer: Monida Allegiance	$26.60
Rate for Payer: Monida First Choice Health	$27.16
Rate for Payer: Monida Montana Health Co-op	$26.60
Rate for Payer: Monida PacificSource	$26.60

CHEST SEAL

Facility

$28.00

Hospital Charge Code	80040209
Hospital Revenue Code	270
Min. Negotiated Rate	$19.60
Max. Negotiated Rate	$28.00
Rate for Payer: Aetna Commercial	$26.60
Rate for Payer: Aetna Medicare	$25.20
Rate for Payer: BCBS MT CHIP	$25.20
Rate for Payer: BCBS MT Closed Plan Network	$26.60
Rate for Payer: BCBS MT HealthLink	$25.20
Rate for Payer: BCBS MT Medicare	$25.20
Rate for Payer: BCBS MT POS	$26.60
Rate for Payer: BCBS MT Traditional	$28.00
Rate for Payer: Cash Price	$25.20
Rate for Payer: Cigna Commercial	$26.60
Rate for Payer: Cigna Medicare	$25.20
Rate for Payer: Medicaid All Medicaid	$25.76
Rate for Payer: Medicare All Medicare	$19.60
Rate for Payer: Monida Allegiance	$26.60
Rate for Payer: Monida First Choice Health	$27.16
Rate for Payer: Monida Montana Health Co-op	$26.60
Rate for Payer: Monida PacificSource	$26.60

CHEST TUBE INSERTION TRAY

Facility

$248.00

Hospital Charge Code	80030356
Hospital Revenue Code	270
Min. Negotiated Rate	$173.60
Max. Negotiated Rate	$248.00
Rate for Payer: Aetna Commercial	$235.60
Rate for Payer: Aetna Medicare	$223.20
Rate for Payer: BCBS MT CHIP	$223.20
Rate for Payer: BCBS MT Closed Plan Network	$235.60
Rate for Payer: BCBS MT HealthLink	$223.20
Rate for Payer: BCBS MT Medicare	$223.20
Rate for Payer: BCBS MT POS	$235.60
Rate for Payer: BCBS MT Traditional	$248.00
Rate for Payer: Cash Price	$223.20
Rate for Payer: Cigna Commercial	$235.60
Rate for Payer: Cigna Medicare	$223.20
Rate for Payer: Medicaid All Medicaid	$228.16
Rate for Payer: Medicare All Medicare	$173.60
Rate for Payer: Monida Allegiance	$235.60
Rate for Payer: Monida First Choice Health	$240.56
Rate for Payer: Monida Montana Health Co-op	$235.60
Rate for Payer: Monida PacificSource	$235.60

CHEST TUBE INSERTION TRAY

Facility

$248.00

Hospital Charge Code	80030356
Hospital Revenue Code	270
Min. Negotiated Rate	$173.60
Max. Negotiated Rate	$248.00
Rate for Payer: Aetna Commercial	$235.60
Rate for Payer: Aetna Medicare	$223.20
Rate for Payer: BCBS MT CHIP	$223.20
Rate for Payer: BCBS MT Closed Plan Network	$235.60
Rate for Payer: BCBS MT HealthLink	$223.20
Rate for Payer: BCBS MT Medicare	$223.20
Rate for Payer: BCBS MT POS	$235.60
Rate for Payer: BCBS MT Traditional	$248.00
Rate for Payer: Cash Price	$223.20
Rate for Payer: Cigna Commercial	$235.60
Rate for Payer: Cigna Medicare	$223.20
Rate for Payer: Medicaid All Medicaid	$228.16
Rate for Payer: Medicare All Medicare	$173.60
Rate for Payer: Monida Allegiance	$235.60
Rate for Payer: Monida First Choice Health	$240.56
Rate for Payer: Monida Montana Health Co-op	$235.60
Rate for Payer: Monida PacificSource	$235.60

CHIRO ADJ 1-2 REG

Facility

$52.00

Service Code	CPT 98940
Hospital Charge Code	8198940
Hospital Revenue Code	521
Min. Negotiated Rate	$36.40
Max. Negotiated Rate	$52.00
Rate for Payer: Aetna Commercial	$49.40
Rate for Payer: Aetna Medicare	$46.80
Rate for Payer: BCBS MT CHIP	$46.80
Rate for Payer: BCBS MT Closed Plan Network	$49.40
Rate for Payer: BCBS MT HealthLink	$46.80
Rate for Payer: BCBS MT Medicare	$46.80
Rate for Payer: BCBS MT POS	$49.40
Rate for Payer: BCBS MT Traditional	$52.00
Rate for Payer: Cash Price	$46.80
Rate for Payer: Cigna Commercial	$49.40
Rate for Payer: Cigna Medicare	$46.80
Rate for Payer: Medicaid All Medicaid	$47.84
Rate for Payer: Medicare All Medicare	$36.40
Rate for Payer: Monida Allegiance	$49.40
Rate for Payer: Monida First Choice Health	$50.44
Rate for Payer: Monida Montana Health Co-op	$49.40
Rate for Payer: Monida PacificSource	$49.40

CHIRO ADJ 1-2 REG

Facility

$52.00

Service Code	CPT 98940
Hospital Charge Code	8198940
Hospital Revenue Code	521
Min. Negotiated Rate	$36.40
Max. Negotiated Rate	$52.00
Rate for Payer: Aetna Commercial	$49.40
Rate for Payer: Aetna Medicare	$46.80
Rate for Payer: BCBS MT CHIP	$46.80
Rate for Payer: BCBS MT Closed Plan Network	$49.40
Rate for Payer: BCBS MT HealthLink	$46.80
Rate for Payer: BCBS MT Medicare	$46.80
Rate for Payer: BCBS MT POS	$49.40
Rate for Payer: BCBS MT Traditional	$52.00
Rate for Payer: Cash Price	$46.80
Rate for Payer: Cigna Commercial	$49.40
Rate for Payer: Cigna Medicare	$46.80
Rate for Payer: Medicaid All Medicaid	$47.84
Rate for Payer: Medicare All Medicare	$36.40
Rate for Payer: Monida Allegiance	$49.40
Rate for Payer: Monida First Choice Health	$50.44
Rate for Payer: Monida Montana Health Co-op	$49.40
Rate for Payer: Monida PacificSource	$49.40

CHIRO ADJ 3-4 REG

Facility

$58.00

Service Code	CPT 98941
Hospital Charge Code	8198941
Hospital Revenue Code	521
Min. Negotiated Rate	$40.60
Max. Negotiated Rate	$58.00
Rate for Payer: Aetna Commercial	$55.10
Rate for Payer: Aetna Medicare	$52.20
Rate for Payer: BCBS MT CHIP	$52.20
Rate for Payer: BCBS MT Closed Plan Network	$55.10
Rate for Payer: BCBS MT HealthLink	$52.20
Rate for Payer: BCBS MT Medicare	$52.20
Rate for Payer: BCBS MT POS	$55.10
Rate for Payer: BCBS MT Traditional	$58.00
Rate for Payer: Cash Price	$52.20
Rate for Payer: Cigna Commercial	$55.10
Rate for Payer: Cigna Medicare	$52.20
Rate for Payer: Medicaid All Medicaid	$53.36
Rate for Payer: Medicare All Medicare	$40.60
Rate for Payer: Monida Allegiance	$55.10
Rate for Payer: Monida First Choice Health	$56.26
Rate for Payer: Monida Montana Health Co-op	$55.10
Rate for Payer: Monida PacificSource	$55.10

CHIRO ADJ 3-4 REG

Facility

$58.00

Service Code	CPT 98941
Hospital Charge Code	8198941
Hospital Revenue Code	521
Min. Negotiated Rate	$40.60
Max. Negotiated Rate	$58.00
Rate for Payer: Aetna Commercial	$55.10
Rate for Payer: Aetna Medicare	$52.20
Rate for Payer: BCBS MT CHIP	$52.20
Rate for Payer: BCBS MT Closed Plan Network	$55.10
Rate for Payer: BCBS MT HealthLink	$52.20
Rate for Payer: BCBS MT Medicare	$52.20
Rate for Payer: BCBS MT POS	$55.10
Rate for Payer: BCBS MT Traditional	$58.00
Rate for Payer: Cash Price	$52.20
Rate for Payer: Cigna Commercial	$55.10
Rate for Payer: Cigna Medicare	$52.20
Rate for Payer: Medicaid All Medicaid	$53.36
Rate for Payer: Medicare All Medicare	$40.60
Rate for Payer: Monida Allegiance	$55.10
Rate for Payer: Monida First Choice Health	$56.26
Rate for Payer: Monida Montana Health Co-op	$55.10
Rate for Payer: Monida PacificSource	$55.10

CHIRO ADJ 5 REG

Facility

$80.00

Service Code	CPT 98942
Hospital Charge Code	8198942
Hospital Revenue Code	521
Min. Negotiated Rate	$56.00
Max. Negotiated Rate	$80.00
Rate for Payer: Aetna Commercial	$76.00
Rate for Payer: Aetna Medicare	$72.00
Rate for Payer: BCBS MT CHIP	$72.00
Rate for Payer: BCBS MT Closed Plan Network	$76.00
Rate for Payer: BCBS MT HealthLink	$72.00
Rate for Payer: BCBS MT Medicare	$72.00
Rate for Payer: BCBS MT POS	$76.00
Rate for Payer: BCBS MT Traditional	$80.00
Rate for Payer: Cash Price	$72.00
Rate for Payer: Cigna Commercial	$76.00
Rate for Payer: Cigna Medicare	$72.00
Rate for Payer: Medicaid All Medicaid	$73.60
Rate for Payer: Medicare All Medicare	$56.00
Rate for Payer: Monida Allegiance	$76.00
Rate for Payer: Monida First Choice Health	$77.60
Rate for Payer: Monida Montana Health Co-op	$76.00
Rate for Payer: Monida PacificSource	$76.00

CHIRO ADJ 5 REG

Facility

$80.00

Service Code	CPT 98942
Hospital Charge Code	8198942
Hospital Revenue Code	521
Min. Negotiated Rate	$56.00
Max. Negotiated Rate	$80.00
Rate for Payer: Aetna Commercial	$76.00
Rate for Payer: Aetna Medicare	$72.00
Rate for Payer: BCBS MT CHIP	$72.00
Rate for Payer: BCBS MT Closed Plan Network	$76.00
Rate for Payer: BCBS MT HealthLink	$72.00
Rate for Payer: BCBS MT Medicare	$72.00
Rate for Payer: BCBS MT POS	$76.00
Rate for Payer: BCBS MT Traditional	$80.00
Rate for Payer: Cash Price	$72.00
Rate for Payer: Cigna Commercial	$76.00
Rate for Payer: Cigna Medicare	$72.00
Rate for Payer: Medicaid All Medicaid	$73.60
Rate for Payer: Medicare All Medicare	$56.00
Rate for Payer: Monida Allegiance	$76.00
Rate for Payer: Monida First Choice Health	$77.60
Rate for Payer: Monida Montana Health Co-op	$76.00
Rate for Payer: Monida PacificSource	$76.00

Know your out-of-pocket cost for care.

All Charges