Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

CHOLESTEROL, HDL

Facility

$77.00

Service Code	CPT 83718
Hospital Charge Code	4083718
Hospital Revenue Code	301
Min. Negotiated Rate	$53.90
Max. Negotiated Rate	$77.00
Rate for Payer: Aetna Commercial	$73.15
Rate for Payer: Aetna Medicare	$69.30
Rate for Payer: BCBS MT CHIP	$69.30
Rate for Payer: BCBS MT Closed Plan Network	$73.15
Rate for Payer: BCBS MT HealthLink	$69.30
Rate for Payer: BCBS MT Medicare	$69.30
Rate for Payer: BCBS MT POS	$73.15
Rate for Payer: BCBS MT Traditional	$77.00
Rate for Payer: Cash Price	$69.30
Rate for Payer: Cigna Commercial	$73.15
Rate for Payer: Cigna Medicare	$69.30
Rate for Payer: Medicaid All Medicaid	$70.84
Rate for Payer: Medicare All Medicare	$53.90
Rate for Payer: Monida Allegiance	$73.15
Rate for Payer: Monida First Choice Health	$74.69
Rate for Payer: Monida Montana Health Co-op	$73.15
Rate for Payer: Monida PacificSource	$73.15

CHOLESTEROL, TOTAL

Facility

$57.00

Service Code	CPT 82465
Hospital Charge Code	4082465
Hospital Revenue Code	301
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

CHOLESTEROL, TOTAL

Facility

$57.00

Service Code	CPT 82465
Hospital Charge Code	4082465
Hospital Revenue Code	301
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

CHOLESTYRAMINE POWDER [4 GM] PK

Facility

$11.00

Service Code	HCPCS J8499
Hospital Charge Code	3000087
Hospital Revenue Code	250
Min. Negotiated Rate	$7.70
Max. Negotiated Rate	$11.00
Rate for Payer: Aetna Commercial	$10.45
Rate for Payer: Aetna Medicare	$9.90
Rate for Payer: BCBS MT CHIP	$9.90
Rate for Payer: BCBS MT Closed Plan Network	$10.45
Rate for Payer: BCBS MT HealthLink	$9.90
Rate for Payer: BCBS MT Medicare	$9.90
Rate for Payer: BCBS MT POS	$10.45
Rate for Payer: BCBS MT Traditional	$11.00
Rate for Payer: Cash Price	$9.90
Rate for Payer: Cigna Commercial	$10.45
Rate for Payer: Cigna Medicare	$9.90
Rate for Payer: Medicaid All Medicaid	$10.12
Rate for Payer: Medicare All Medicare	$7.70
Rate for Payer: Monida Allegiance	$10.45
Rate for Payer: Monida First Choice Health	$10.67
Rate for Payer: Monida Montana Health Co-op	$10.45
Rate for Payer: Monida PacificSource	$10.45

CHOLESTYRAMINE POWDER [4 GM] PK

Facility

$11.00

Service Code	HCPCS J8499
Hospital Charge Code	3000087
Hospital Revenue Code	250
Min. Negotiated Rate	$7.70
Max. Negotiated Rate	$11.00
Rate for Payer: Aetna Commercial	$10.45
Rate for Payer: Aetna Medicare	$9.90
Rate for Payer: BCBS MT CHIP	$9.90
Rate for Payer: BCBS MT Closed Plan Network	$10.45
Rate for Payer: BCBS MT HealthLink	$9.90
Rate for Payer: BCBS MT Medicare	$9.90
Rate for Payer: BCBS MT POS	$10.45
Rate for Payer: BCBS MT Traditional	$11.00
Rate for Payer: Cash Price	$9.90
Rate for Payer: Cigna Commercial	$10.45
Rate for Payer: Cigna Medicare	$9.90
Rate for Payer: Medicaid All Medicaid	$10.12
Rate for Payer: Medicare All Medicare	$7.70
Rate for Payer: Monida Allegiance	$10.45
Rate for Payer: Monida First Choice Health	$10.67
Rate for Payer: Monida Montana Health Co-op	$10.45
Rate for Payer: Monida PacificSource	$10.45

CHROMATIN AB IGG

Facility

$115.00

Service Code	CPT 83516
Hospital Charge Code	4088109
Hospital Revenue Code	302
Min. Negotiated Rate	$80.50
Max. Negotiated Rate	$115.00
Rate for Payer: Aetna Commercial	$109.25
Rate for Payer: Aetna Medicare	$103.50
Rate for Payer: BCBS MT CHIP	$103.50
Rate for Payer: BCBS MT Closed Plan Network	$109.25
Rate for Payer: BCBS MT HealthLink	$103.50
Rate for Payer: BCBS MT Medicare	$103.50
Rate for Payer: BCBS MT POS	$109.25
Rate for Payer: BCBS MT Traditional	$115.00
Rate for Payer: Cash Price	$103.50
Rate for Payer: Cigna Commercial	$109.25
Rate for Payer: Cigna Medicare	$103.50
Rate for Payer: Medicaid All Medicaid	$105.80
Rate for Payer: Medicare All Medicare	$80.50
Rate for Payer: Monida Allegiance	$109.25
Rate for Payer: Monida First Choice Health	$111.55
Rate for Payer: Monida Montana Health Co-op	$109.25
Rate for Payer: Monida PacificSource	$109.25

CHROMATIN AB IGG

Facility

$115.00

Service Code	CPT 83516
Hospital Charge Code	4088109
Hospital Revenue Code	302
Min. Negotiated Rate	$80.50
Max. Negotiated Rate	$115.00
Rate for Payer: Aetna Commercial	$109.25
Rate for Payer: Aetna Medicare	$103.50
Rate for Payer: BCBS MT CHIP	$103.50
Rate for Payer: BCBS MT Closed Plan Network	$109.25
Rate for Payer: BCBS MT HealthLink	$103.50
Rate for Payer: BCBS MT Medicare	$103.50
Rate for Payer: BCBS MT POS	$109.25
Rate for Payer: BCBS MT Traditional	$115.00
Rate for Payer: Cash Price	$103.50
Rate for Payer: Cigna Commercial	$109.25
Rate for Payer: Cigna Medicare	$103.50
Rate for Payer: Medicaid All Medicaid	$105.80
Rate for Payer: Medicare All Medicare	$80.50
Rate for Payer: Monida Allegiance	$109.25
Rate for Payer: Monida First Choice Health	$111.55
Rate for Payer: Monida Montana Health Co-op	$109.25
Rate for Payer: Monida PacificSource	$109.25

CHROMIUM (071522)

Facility

$105.00

Service Code	CPT 82495
Hospital Charge Code	4082495
Hospital Revenue Code	300
Min. Negotiated Rate	$73.50
Max. Negotiated Rate	$105.00
Rate for Payer: Aetna Commercial	$99.75
Rate for Payer: Aetna Medicare	$94.50
Rate for Payer: BCBS MT CHIP	$94.50
Rate for Payer: BCBS MT Closed Plan Network	$99.75
Rate for Payer: BCBS MT HealthLink	$94.50
Rate for Payer: BCBS MT Medicare	$94.50
Rate for Payer: BCBS MT POS	$99.75
Rate for Payer: BCBS MT Traditional	$105.00
Rate for Payer: Cash Price	$94.50
Rate for Payer: Cigna Commercial	$99.75
Rate for Payer: Cigna Medicare	$94.50
Rate for Payer: Medicaid All Medicaid	$96.60
Rate for Payer: Medicare All Medicare	$73.50
Rate for Payer: Monida Allegiance	$99.75
Rate for Payer: Monida First Choice Health	$101.85
Rate for Payer: Monida Montana Health Co-op	$99.75
Rate for Payer: Monida PacificSource	$99.75

CHROMIUM (071522)

Facility

$105.00

Service Code	CPT 82495
Hospital Charge Code	4082495
Hospital Revenue Code	300
Min. Negotiated Rate	$73.50
Max. Negotiated Rate	$105.00
Rate for Payer: Aetna Commercial	$99.75
Rate for Payer: Aetna Medicare	$94.50
Rate for Payer: BCBS MT CHIP	$94.50
Rate for Payer: BCBS MT Closed Plan Network	$99.75
Rate for Payer: BCBS MT HealthLink	$94.50
Rate for Payer: BCBS MT Medicare	$94.50
Rate for Payer: BCBS MT POS	$99.75
Rate for Payer: BCBS MT Traditional	$105.00
Rate for Payer: Cash Price	$94.50
Rate for Payer: Cigna Commercial	$99.75
Rate for Payer: Cigna Medicare	$94.50
Rate for Payer: Medicaid All Medicaid	$96.60
Rate for Payer: Medicare All Medicare	$73.50
Rate for Payer: Monida Allegiance	$99.75
Rate for Payer: Monida First Choice Health	$101.85
Rate for Payer: Monida Montana Health Co-op	$99.75
Rate for Payer: Monida PacificSource	$99.75

CHROMOGRANIN A

Facility

$112.00

Service Code	CPT 86316
Hospital Charge Code	4088054
Hospital Revenue Code	302
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

CHROMOGRANIN A

Facility

$112.00

Service Code	CPT 86316
Hospital Charge Code	4088054
Hospital Revenue Code	302
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

CHROMOSOME ANALYSIS LEUKEMIC BLD(2002290

Facility

$550.00

Service Code	CPT 88237
Hospital Charge Code	4087993
Hospital Revenue Code	302
Min. Negotiated Rate	$385.00
Max. Negotiated Rate	$550.00
Rate for Payer: Aetna Commercial	$522.50
Rate for Payer: Aetna Medicare	$495.00
Rate for Payer: BCBS MT CHIP	$495.00
Rate for Payer: BCBS MT Closed Plan Network	$522.50
Rate for Payer: BCBS MT HealthLink	$495.00
Rate for Payer: BCBS MT Medicare	$495.00
Rate for Payer: BCBS MT POS	$522.50
Rate for Payer: BCBS MT Traditional	$550.00
Rate for Payer: Cash Price	$495.00
Rate for Payer: Cigna Commercial	$522.50
Rate for Payer: Cigna Medicare	$495.00
Rate for Payer: Medicaid All Medicaid	$506.00
Rate for Payer: Medicare All Medicare	$385.00
Rate for Payer: Monida Allegiance	$522.50
Rate for Payer: Monida First Choice Health	$533.50
Rate for Payer: Monida Montana Health Co-op	$522.50
Rate for Payer: Monida PacificSource	$522.50

CHROMOSOME ANALYSIS LEUKEMIC BLD(2002290

Facility

$550.00

Service Code	CPT 88237
Hospital Charge Code	4087993
Hospital Revenue Code	302
Min. Negotiated Rate	$385.00
Max. Negotiated Rate	$550.00
Rate for Payer: Aetna Commercial	$522.50
Rate for Payer: Aetna Medicare	$495.00
Rate for Payer: BCBS MT CHIP	$495.00
Rate for Payer: BCBS MT Closed Plan Network	$522.50
Rate for Payer: BCBS MT HealthLink	$495.00
Rate for Payer: BCBS MT Medicare	$495.00
Rate for Payer: BCBS MT POS	$522.50
Rate for Payer: BCBS MT Traditional	$550.00
Rate for Payer: Cash Price	$495.00
Rate for Payer: Cigna Commercial	$522.50
Rate for Payer: Cigna Medicare	$495.00
Rate for Payer: Medicaid All Medicaid	$506.00
Rate for Payer: Medicare All Medicare	$385.00
Rate for Payer: Monida Allegiance	$522.50
Rate for Payer: Monida First Choice Health	$533.50
Rate for Payer: Monida Montana Health Co-op	$522.50
Rate for Payer: Monida PacificSource	$522.50

CHROMOSOME FISH CLL PANEL(2002295

Facility

$800.00

Service Code	CPT 88271
Hospital Charge Code	4087994
Hospital Revenue Code	302
Min. Negotiated Rate	$560.00
Max. Negotiated Rate	$800.00
Rate for Payer: Aetna Commercial	$760.00
Rate for Payer: Aetna Medicare	$720.00
Rate for Payer: BCBS MT CHIP	$720.00
Rate for Payer: BCBS MT Closed Plan Network	$760.00
Rate for Payer: BCBS MT HealthLink	$720.00
Rate for Payer: BCBS MT Medicare	$720.00
Rate for Payer: BCBS MT POS	$760.00
Rate for Payer: BCBS MT Traditional	$800.00
Rate for Payer: Cash Price	$720.00
Rate for Payer: Cigna Commercial	$760.00
Rate for Payer: Cigna Medicare	$720.00
Rate for Payer: Medicaid All Medicaid	$736.00
Rate for Payer: Medicare All Medicare	$560.00
Rate for Payer: Monida Allegiance	$760.00
Rate for Payer: Monida First Choice Health	$776.00
Rate for Payer: Monida Montana Health Co-op	$760.00
Rate for Payer: Monida PacificSource	$760.00

CHROMOSOME FISH CLL PANEL(2002295

Facility

$800.00

Service Code	CPT 88271
Hospital Charge Code	4087994
Hospital Revenue Code	302
Min. Negotiated Rate	$560.00
Max. Negotiated Rate	$800.00
Rate for Payer: Aetna Commercial	$760.00
Rate for Payer: Aetna Medicare	$720.00
Rate for Payer: BCBS MT CHIP	$720.00
Rate for Payer: BCBS MT Closed Plan Network	$760.00
Rate for Payer: BCBS MT HealthLink	$720.00
Rate for Payer: BCBS MT Medicare	$720.00
Rate for Payer: BCBS MT POS	$760.00
Rate for Payer: BCBS MT Traditional	$800.00
Rate for Payer: Cash Price	$720.00
Rate for Payer: Cigna Commercial	$760.00
Rate for Payer: Cigna Medicare	$720.00
Rate for Payer: Medicaid All Medicaid	$736.00
Rate for Payer: Medicare All Medicare	$560.00
Rate for Payer: Monida Allegiance	$760.00
Rate for Payer: Monida First Choice Health	$776.00
Rate for Payer: Monida Montana Health Co-op	$760.00
Rate for Payer: Monida PacificSource	$760.00

CHROMOSONE ANALYSIS CONSTI PERIPHERAL BL

Facility

$150.00

Service Code	CPT 88262
Hospital Charge Code	4088148
Hospital Revenue Code	301
Min. Negotiated Rate	$105.00
Max. Negotiated Rate	$150.00
Rate for Payer: Aetna Commercial	$142.50
Rate for Payer: Aetna Medicare	$135.00
Rate for Payer: BCBS MT CHIP	$135.00
Rate for Payer: BCBS MT Closed Plan Network	$142.50
Rate for Payer: BCBS MT HealthLink	$135.00
Rate for Payer: BCBS MT Medicare	$135.00
Rate for Payer: BCBS MT POS	$142.50
Rate for Payer: BCBS MT Traditional	$150.00
Rate for Payer: Cash Price	$135.00
Rate for Payer: Cigna Commercial	$142.50
Rate for Payer: Cigna Medicare	$135.00
Rate for Payer: Medicaid All Medicaid	$138.00
Rate for Payer: Medicare All Medicare	$105.00
Rate for Payer: Monida Allegiance	$142.50
Rate for Payer: Monida First Choice Health	$145.50
Rate for Payer: Monida Montana Health Co-op	$142.50
Rate for Payer: Monida PacificSource	$142.50

CHROMOSONE ANALYSIS CONSTI PERIPHERAL BL

Facility

$150.00

Service Code	CPT 88262
Hospital Charge Code	4088148
Hospital Revenue Code	301
Min. Negotiated Rate	$105.00
Max. Negotiated Rate	$150.00
Rate for Payer: Aetna Commercial	$142.50
Rate for Payer: Aetna Medicare	$135.00
Rate for Payer: BCBS MT CHIP	$135.00
Rate for Payer: BCBS MT Closed Plan Network	$142.50
Rate for Payer: BCBS MT HealthLink	$135.00
Rate for Payer: BCBS MT Medicare	$135.00
Rate for Payer: BCBS MT POS	$142.50
Rate for Payer: BCBS MT Traditional	$150.00
Rate for Payer: Cash Price	$135.00
Rate for Payer: Cigna Commercial	$142.50
Rate for Payer: Cigna Medicare	$135.00
Rate for Payer: Medicaid All Medicaid	$138.00
Rate for Payer: Medicare All Medicare	$105.00
Rate for Payer: Monida Allegiance	$142.50
Rate for Payer: Monida First Choice Health	$145.50
Rate for Payer: Monida Montana Health Co-op	$142.50
Rate for Payer: Monida PacificSource	$142.50

CHROMOSONE ANALYSIS ROUTINE

Facility

$110.00

Service Code	CPT 88262
Hospital Charge Code	4088262
Hospital Revenue Code	301
Min. Negotiated Rate	$77.00
Max. Negotiated Rate	$110.00
Rate for Payer: Aetna Commercial	$104.50
Rate for Payer: Aetna Medicare	$99.00
Rate for Payer: BCBS MT CHIP	$99.00
Rate for Payer: BCBS MT Closed Plan Network	$104.50
Rate for Payer: BCBS MT HealthLink	$99.00
Rate for Payer: BCBS MT Medicare	$99.00
Rate for Payer: BCBS MT POS	$104.50
Rate for Payer: BCBS MT Traditional	$110.00
Rate for Payer: Cash Price	$99.00
Rate for Payer: Cigna Commercial	$104.50
Rate for Payer: Cigna Medicare	$99.00
Rate for Payer: Medicaid All Medicaid	$101.20
Rate for Payer: Medicare All Medicare	$77.00
Rate for Payer: Monida Allegiance	$104.50
Rate for Payer: Monida First Choice Health	$106.70
Rate for Payer: Monida Montana Health Co-op	$104.50
Rate for Payer: Monida PacificSource	$104.50

CHROMOSONE ANALYSIS ROUTINE

Facility

$110.00

Service Code	CPT 88262
Hospital Charge Code	4088262
Hospital Revenue Code	301
Min. Negotiated Rate	$77.00
Max. Negotiated Rate	$110.00
Rate for Payer: Aetna Commercial	$104.50
Rate for Payer: Aetna Medicare	$99.00
Rate for Payer: BCBS MT CHIP	$99.00
Rate for Payer: BCBS MT Closed Plan Network	$104.50
Rate for Payer: BCBS MT HealthLink	$99.00
Rate for Payer: BCBS MT Medicare	$99.00
Rate for Payer: BCBS MT POS	$104.50
Rate for Payer: BCBS MT Traditional	$110.00
Rate for Payer: Cash Price	$99.00
Rate for Payer: Cigna Commercial	$104.50
Rate for Payer: Cigna Medicare	$99.00
Rate for Payer: Medicaid All Medicaid	$101.20
Rate for Payer: Medicare All Medicare	$77.00
Rate for Payer: Monida Allegiance	$104.50
Rate for Payer: Monida First Choice Health	$106.70
Rate for Payer: Monida Montana Health Co-op	$104.50
Rate for Payer: Monida PacificSource	$104.50

CHRONIC CARE MGMT, 20 MIN

Facility

$165.00

Service Code	CPT 99490
Hospital Charge Code	8099490
Hospital Revenue Code	521
Min. Negotiated Rate	$115.50
Max. Negotiated Rate	$165.00
Rate for Payer: Aetna Commercial	$156.75
Rate for Payer: Aetna Medicare	$148.50
Rate for Payer: BCBS MT CHIP	$148.50
Rate for Payer: BCBS MT Closed Plan Network	$156.75
Rate for Payer: BCBS MT HealthLink	$148.50
Rate for Payer: BCBS MT Medicare	$148.50
Rate for Payer: BCBS MT POS	$156.75
Rate for Payer: BCBS MT Traditional	$165.00
Rate for Payer: Cash Price	$148.50
Rate for Payer: Cigna Commercial	$156.75
Rate for Payer: Cigna Medicare	$148.50
Rate for Payer: Medicaid All Medicaid	$151.80
Rate for Payer: Medicare All Medicare	$115.50
Rate for Payer: Monida Allegiance	$156.75
Rate for Payer: Monida First Choice Health	$160.05
Rate for Payer: Monida Montana Health Co-op	$156.75
Rate for Payer: Monida PacificSource	$156.75

CHRONIC CARE MGMT, 20 MIN

Facility

$165.00

Service Code	CPT 99490
Hospital Charge Code	8099490
Hospital Revenue Code	521
Min. Negotiated Rate	$115.50
Max. Negotiated Rate	$165.00
Rate for Payer: Aetna Commercial	$156.75
Rate for Payer: Aetna Medicare	$148.50
Rate for Payer: BCBS MT CHIP	$148.50
Rate for Payer: BCBS MT Closed Plan Network	$156.75
Rate for Payer: BCBS MT HealthLink	$148.50
Rate for Payer: BCBS MT Medicare	$148.50
Rate for Payer: BCBS MT POS	$156.75
Rate for Payer: BCBS MT Traditional	$165.00
Rate for Payer: Cash Price	$148.50
Rate for Payer: Cigna Commercial	$156.75
Rate for Payer: Cigna Medicare	$148.50
Rate for Payer: Medicaid All Medicaid	$151.80
Rate for Payer: Medicare All Medicare	$115.50
Rate for Payer: Monida Allegiance	$156.75
Rate for Payer: Monida First Choice Health	$160.05
Rate for Payer: Monida Montana Health Co-op	$156.75
Rate for Payer: Monida PacificSource	$156.75

CHRONIC CARE MGMT 60 PLUS MIN COMPLEX

Facility

$360.00

Service Code	CPT 99487
Hospital Charge Code	8099487
Hospital Revenue Code	521
Min. Negotiated Rate	$252.00
Max. Negotiated Rate	$360.00
Rate for Payer: Aetna Commercial	$342.00
Rate for Payer: Aetna Medicare	$324.00
Rate for Payer: BCBS MT CHIP	$324.00
Rate for Payer: BCBS MT Closed Plan Network	$342.00
Rate for Payer: BCBS MT HealthLink	$324.00
Rate for Payer: BCBS MT Medicare	$324.00
Rate for Payer: BCBS MT POS	$342.00
Rate for Payer: BCBS MT Traditional	$360.00
Rate for Payer: Cash Price	$324.00
Rate for Payer: Cigna Commercial	$342.00
Rate for Payer: Cigna Medicare	$324.00
Rate for Payer: Medicaid All Medicaid	$331.20
Rate for Payer: Medicare All Medicare	$252.00
Rate for Payer: Monida Allegiance	$342.00
Rate for Payer: Monida First Choice Health	$349.20
Rate for Payer: Monida Montana Health Co-op	$342.00
Rate for Payer: Monida PacificSource	$342.00

CHRONIC CARE MGMT 60 PLUS MIN COMPLEX

Facility

$360.00

Service Code	CPT 99487
Hospital Charge Code	8099487
Hospital Revenue Code	521
Min. Negotiated Rate	$252.00
Max. Negotiated Rate	$360.00
Rate for Payer: Aetna Commercial	$342.00
Rate for Payer: Aetna Medicare	$324.00
Rate for Payer: BCBS MT CHIP	$324.00
Rate for Payer: BCBS MT Closed Plan Network	$342.00
Rate for Payer: BCBS MT HealthLink	$324.00
Rate for Payer: BCBS MT Medicare	$324.00
Rate for Payer: BCBS MT POS	$342.00
Rate for Payer: BCBS MT Traditional	$360.00
Rate for Payer: Cash Price	$324.00
Rate for Payer: Cigna Commercial	$342.00
Rate for Payer: Cigna Medicare	$324.00
Rate for Payer: Medicaid All Medicaid	$331.20
Rate for Payer: Medicare All Medicare	$252.00
Rate for Payer: Monida Allegiance	$342.00
Rate for Payer: Monida First Choice Health	$349.20
Rate for Payer: Monida Montana Health Co-op	$342.00
Rate for Payer: Monida PacificSource	$342.00

CHRONIC CARE MGMT, ADD'T 20 MIN

Facility

$126.00

Service Code	CPT 99439
Hospital Charge Code	8099439
Hospital Revenue Code	521
Min. Negotiated Rate	$88.20
Max. Negotiated Rate	$126.00
Rate for Payer: Aetna Commercial	$119.70
Rate for Payer: Aetna Medicare	$113.40
Rate for Payer: BCBS MT CHIP	$113.40
Rate for Payer: BCBS MT Closed Plan Network	$119.70
Rate for Payer: BCBS MT HealthLink	$113.40
Rate for Payer: BCBS MT Medicare	$113.40
Rate for Payer: BCBS MT POS	$119.70
Rate for Payer: BCBS MT Traditional	$126.00
Rate for Payer: Cash Price	$113.40
Rate for Payer: Cigna Commercial	$119.70
Rate for Payer: Cigna Medicare	$113.40
Rate for Payer: Medicaid All Medicaid	$115.92
Rate for Payer: Medicare All Medicare	$88.20
Rate for Payer: Monida Allegiance	$119.70
Rate for Payer: Monida First Choice Health	$122.22
Rate for Payer: Monida Montana Health Co-op	$119.70
Rate for Payer: Monida PacificSource	$119.70

CHRONIC CARE MGMT, ADD'T 20 MIN

Facility

$126.00

Service Code	CPT 99439
Hospital Charge Code	8099439
Hospital Revenue Code	521
Min. Negotiated Rate	$88.20
Max. Negotiated Rate	$126.00
Rate for Payer: Aetna Commercial	$119.70
Rate for Payer: Aetna Medicare	$113.40
Rate for Payer: BCBS MT CHIP	$113.40
Rate for Payer: BCBS MT Closed Plan Network	$119.70
Rate for Payer: BCBS MT HealthLink	$113.40
Rate for Payer: BCBS MT Medicare	$113.40
Rate for Payer: BCBS MT POS	$119.70
Rate for Payer: BCBS MT Traditional	$126.00
Rate for Payer: Cash Price	$113.40
Rate for Payer: Cigna Commercial	$119.70
Rate for Payer: Cigna Medicare	$113.40
Rate for Payer: Medicaid All Medicaid	$115.92
Rate for Payer: Medicare All Medicare	$88.20
Rate for Payer: Monida Allegiance	$119.70
Rate for Payer: Monida First Choice Health	$122.22
Rate for Payer: Monida Montana Health Co-op	$119.70
Rate for Payer: Monida PacificSource	$119.70

Know your out-of-pocket cost for care.

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